by Halko Weiss
Given the above cautions, therapeutic work that incorporates experience-activating, experimental, and body-oriented approaches is not suited for immediate implementation with clients that are organizationally or structurally fragile. These clients do not have enough inner structure accessible to be able to process and integrate the meaning of the material that would arise, nor would they be able to tolerate the degree of psychophysiological arousal that would accompany this material. This means that the foundation of the explorative Hakomi method—the mindful exploration of present-moment experience—would not be possible to execute uncritically at the outset of therapy. The practice of mindfulness with closed eyes, and even the invitation to physical relaxation, triggers the fear of having to give up or lose control—a control that is often maintained through the musculature, which requires tension in order to mask sensitivity (Reich, 1949). As always, the Hakomi principles trump the automatic imposition of any techniques. Sometimes intrapsychic mindfulness must be foregone in favor of structure-building mindfulness that helps those who are fragile to connect to reality. For example, asking the client, “Can you hear my voice? How do you know you are hearing it? Can you feel your feet on the ground? What tells you that you are feeling them? Stamp your foot and notice the sensation when it hits the ground.”
Another aspect of this discussion relates to the therapeutic relationship itself. The interactional style of early-deficit clients is likely to strain relationships with others, and makes constructive interpersonal relationships difficult, or even impossible (Rudolf, 1996). The countertransference that is evoked can, of course, give the Hakomi therapist clues to how such a person organizes his world, and what kinds of life situations might have created that organization (Stolorow et al., 1987). With the limitations of early, structural-level deficits in mind, the following are examples of scenarios that present challenges to Hakomi-oriented therapists disposed to jump in with classic methods. They highlight the challenges and potential pitfalls to be aware of when engaging in such work.
For individuals with borderline features, defense mechanisms such as splitting, projection, denial, and idealization serve to protect against the disintegration of the self. (“The self” here refers to the psychoanalytic sense of an intrapersonal structure of the ego, or I.) Images of self and other fall into “all-good” and “all-bad” parts, where the negative aspects are projected outside the self. The relationships entered into by someone with these relational habits—splitting, idealization, demonization, or projection—are extremely difficult (Rudolf, 1996). If the severity of the disorder is significant enough, the level of distress, fear, frustration, and so forth leads to unbearable tension and arousal that often prevents clients with these problematic patterns from being able to observe these phenomena within themselves. These clients are in a timeless experience of elevated stress that is made manageable only through dissipation efforts such as movement, self-injury, or the use of soothing substances. To respond to these clients in therapeutically helpful ways presents a special challenge to therapists’ own inner stability. However, as Linehan’s work has demonstrated (Robins, Schmidt, & Linehan, 2004), mindfulness has an important part to play in the treatment of borderline dispositions when combined with the appropriate structures.
For those with more narcissistically colored personality structures, the fear that a deeper connection with others would expose both feelings of worthlessness and the helpless neediness of a fragile self leads these individuals to protect against deeper relationships. This tendency will also apply to their relationships with their therapists. A client with this type of organizational structure may attempt to devalue and control the therapist in order to “maintain a sense of grandiosity against all attempts at reality testing” (Rudolf, 1996, p. 178). As uncomfortable and difficult as this type of limited relationship is for the therapist striving for a “real connection” with the client, it serves to maintain the “survival” of the client in the narrow sense of the word. This type of protection and stabilization system cannot be jumped out of or exploded—given the client’s deficiencies in internal structure, this would lead to the disintegration and decompensation of the client’s fragile self. Hakomi therapists must be careful to moderate their own countertransference, as these clients with lack of stable self-structures can bounce back and forth between needs to be independent or in control to the more needy positions that scare them.
Thinking about the above in connection with the classic Hakomi approach to therapeutic process outlined in Chapter 21, the inner logic of Hakomi can suggest where modifications might be necessary in order to continue to be helpful to clients without sufficient access to the resources that are prerequisites for normal work, such as the deficits in perception, regulation, communication, and connection referenced above. An important part of client evaluation is an assessment of how much of a self-state characterized by awareness and compassion they have available, even though they might have had significant developmental traumas (Almaas, 1986; Eisman, 2006; Schwartz, 1995). Borderline and narcissistic personality disorders commonly reveal themselves as disorders of the self.
A special characteristic of the therapeutic relationship in the Hakomi approach, for example, is found in the therapist’s interest in making self-awareness accessible to the client when exploring the barriers to growth and transformation associated with the defense mechanisms. Examples of this are seen in a Hakomi therapist creating experiments in mindfulness (Chapter 16) such as, “What happens inside when you hear [pause] . . . ‘You are safe here,’” or “What happens inside when you hear [pause] . . . ‘You are welcomed with all my heart!’” Individuals who have developed healthy internal structure will be able to understand the experimental setting and make use of the evoked experience to study their own self-organization and relevant inner reactions—thoughts, feelings, images, memories, and impulses.
An individual’s psychostructural limitations can become apparent, however, in his or her ability to engage in such imaginative exercises. “As-if” experiments require an understanding on the part of the ego that enables clients to see the meaning of the therapist’s offered scenarios as opportunities to study their personal reactions, as opposed to literal interpersonal offerings from the therapist. Often in work with clients with severe structural limitations, invitations to engage in self-observation might not be possible. Some clients cannot understand or experience the experimental “as-if” situation as such, even with additional efforts toward clarification. The Hakomi experiments most easily misunderstood are those stated by the therapist in the first person, such as, “I am here for you.” Similar difficulties can be found when taking over an introjected voice, which can trigger significant irritation on the part of the client (such as reacting with “Why are you talking to me like my mother did?”). The client’s ability to be mindfully self-reflective is a crucial assessment in the decision to employ Hakomi accessing techniques (Chapter 15).
Nonverbal experiments incorporating touch or body-oriented techniques can make the clients’ structural limitation-based difficulties even clearer. For clients with structural deficits, an experimental touch could be interpreted as a direct relationship statement. Utilizing the technique of taking over (Chapter 17) a client’s shoulder tension could be interpreted as a relational statement that leads to a habituated response, such as, “That feels good,” or “That’s awfully nice of you,” with the client interpreting the touch as a sign of personal support or compassion, instead of an opportunity for mindful experiential reflection (such as, “Wow, I’m noticing my stomach getting warm and I’m noticing myself beginning to feel joyful”). Thus, Hakomi therapists need to continually track whether the client is reactive or reflective, and whether the client is in fact capable of taking herself under observation.
Similar warnings apply to inner child (Chapter 18) work. On the one hand, when working with possible “missing experiences” in the sense of providing missing parenting or facilitating missing maturation p
rocesses, the therapist may take on the ideal role of the protective parent originally not present (Pesso, 1973). In this role, the therapist may, for example, let the “child” attempt to introject the feeling of being physically held and to explore what it is like to be protected. In these situations, there is a danger that instead of integrating the protective parent role into their own structure as a role that they can perform for themselves, a relationship can arise in which clients become dependent on the therapist (as helper-ego) to perform this role. Here, Hakomi therapists must track to make sure clients are always in a dual state of consciousness: sensing the developmental reality of the child alongside their adult consciousness that is aware they are in a therapy process. Sometimes it is helpful to collaborate with the client by asking, “Should I communicate to the child the missing experience or is it good that you do it?” Or, in the integration phase of the work (Chapter 20), after the client has taken in the felt knowledge of the missing experience from without, the therapist can help empower the client’s larger self-state from within by saying, “Now how about you say to the child what he heard from me earlier, that he is safe now, and notice if he takes it in.”
There is an additional danger, however, in playing the magical stranger role (Chapter 18) when working with significantly traumatized individuals, such as those who were sexually abused as children. If the therapist goes into the role of the good adult prematurely, without resourcing the client and making it clear that she is going to titrate the trauma (Levine with Frederick, 1997) by not operating outside the client’s window of tolerance, the process could lead to retraumatization. This could result in the client feeling frighteningly small and powerless, fused or blended with the memories through which the powerless sense of being a victim were originally stabilized. Inner child work and the role of the magical stranger, as originally taught in Hakomi, have been modified over the last 30 years as more about trauma, resourcing, titrating, and having the witness or larger self-states on board has become apparent through both experience and theory arising from current research.
One modified approach to inner child work suggested above that can be helpful is to invite contact with the inner child from the adult part of the client. Sometimes the adult part will know what to say to the inner child, and sometimes this part can give a suggestion on the therapist’s behalf. Such an exchange might go as follows:
THERAPIST: Could you ask little Lisa if she wants to show us more today?
ADULT LISA: She says no more for today—but she likes that we believe her!
This, then, is a three-way collaboration between the therapist, inner child, and the adult part or self-state of the client. From the perspective of developing self-empowerment and self-regulation, this approach is one way of keeping the client in control and serves to minimize the risk of a traumatic regression into a feeling of powerlessness.
A final note regarding physical touch. Research has taught us that physical touch can trigger so-called body memories that reside in procedural and implicit memory and have not been made available to meaning-giving explicit memory (Chapter 4). These body memories can, in turn, trigger automated flashbacks that can retraumatize the client (Levine with Frederick, 1997; Yehuda & McFarlane, 1997). Given this, the use of physical touch should be approached with a great deal of caution when therapeutically accompanying traumatized clients through their work. Hakomi assumes the integration of implicit memories and beliefs throughout the spectrum of experience from sensations to tensions, to feelings, to posture and gestures, to thoughts and memories (Caldwell, 1997, 2011; Johanson, 2011c; LeDoux, 1996), knowing that verbal or nonverbal contact can evoke memories at any moment. While the meaning a client makes of touch is always tracked, as is the presence of evoked memories, working with trauma alerts the therapist to be aware of ever-present triggers that neither client nor therapist might know of ahead of time—and of the importance of proceeding with the necessary amount of resourcing so that working with trauma is titrated to a rate that can be assimilated by the client (Chapter 24).
In summary, the defense mechanisms of individuals with structural personality deficits in perception, regulation, communication, and connection should be considered as efforts from their organic wisdom to protect and maintain stability. No defense is ever taken away in Hakomi. The therapy only intends to add new possibilities when a client is able to enter into the transformative process. Defenses should not even be explored for this purpose unless the client is appropriately resourced or until the work has enabled the underlying vulnerable structures to retroactively mature (Rudolf, 1996). The classic Hakomi approach taught in basic training is only applicable when all of the prerequisites below are met by the client in question:
1. An alert, oriented consciousness free of significant distortions or perceptual limitations that would render him unable to take himself under observation is available to the client.
2. The client possesses both the ability for and openness to introspection, self-observation, and mindfulness.
3. The client is capable of disidentifying with particular patterns of experience from time to time in the service of expanding her inner observer or observing ego. (For example, the presence of judgmental, critical parts or overly harsh superego parts must first be dealt with consciously before judgment-free mindfulness can be practiced.)
4. The client is able to enter into a therapeutic relationship, with all that this implies. At a minimum, the client must be able to understand the “as-if” invitations to self-exploration as such.
Further Considerations for Clients With Structural Limitations
Intake and Diagnosis
In order to responsibly proceed with Hakomi’s body-oriented, experience-evoking approach in a manner that is mindful of possible destabilizing effects, the pursuit of a thorough intake process is recommended before actively commencing a course of therapeutic treatment. In addition, diagnosis and overall assessment in Hakomi happen as every experiment from saying hello to shaking hands, to offering a seat is tracked for its effect and contacted at the appropriate level of depth. Hakomi therapists are also continually taking in diagnostic bodily information from the person’s posture, gestures, breathing, rate of speech, relational characteristics, and so forth (Chapters 4 and 23).
The process of diagnosis will continue in a like manner throughout the course of therapy, such that the diagnosis and core material in play become both more differentiated and more precise as the therapeutic work unfolds. Clinical experience with a client will refine the therapist’s perception, as will the therapist’s ability to remain in good contact with herself, her client, and the process unfolding in the present moment. By being attentive to all three of these dimensions, the therapist can track the developments in both the intra- and interpersonal fields of the client as well as in the arena of therapist-client counter-transference. A continual attentiveness to the development of the client’s inner and outer experience, processing, and behavioral possibilities is the deciding factor that enables therapists to respond with interventions that are well attuned to clients’ actual psychological states (Siegel, 2007). When in doubt about going forward with an intervention, it is always appropriate to take time to gain more information before doing so. On the other hand, the Hakomi process is self-correcting in that all therapeutic interventions are done experimentally—yielding results that either confirm or disconfirm the therapist’s clinical intuition (Marks-Tarlow, 2012), and guiding the next level of contact (Chapter 14) for deepening or repairing the therapeutic alliance (Stolorow et al., 1987).
For some clients, therapy will not progress much beyond providing a stabilizing, supportive effect for some time. This will, however, typically be experienced as a significant improvement in these clients’ quality of life. For other clients, once stabilization has taken hold, the goal of psychological maturation and consolidation can be pursued, which in turn can lead to the possibility of pursuing insight-oriented uncovering work. In these cases, it is importa
nt to make decisions in a responsible, collaborative manner, such that clients ultimately determine the direction of the work as well as the approaches and interventions utilized in the service of their therapeutic goals (Duncan, 2010).
Anchoring in the Outer World and in Everyday Consciousness
For clients with structural limitations, anything that supports the stable perception of outer reality is helpful. Sometimes this can involve a limited, bounded, and measured shift into using the mind-body interface in a mindful way that the therapist employs cautiously, continuously tracking for the risk of destabilization. For example:
1. Connecting body awareness and emotion through conscious perception.
The defenses of narcissistic clients often possess an alexithymic quality. According to the results of neurobiological research (Damasio, 2000), the brains of alexithymic individuals are not able to integrate feelings in relation to signals from the body. However, it is possible to create new synaptic connections (such as to the amygdala) through conscious experience of evoked bodily sensations and emotions in the present moment (Thielen, 2002, 2015). In these cases, mindfulness and accessing can aid in joining right- and left-brain functions.
2. Experiencing the body and its boundaries.
Case example: During a long-term course of psychotherapeutic treatment, a 30-year-old woman who was sexually abused as a child became aware that she would leave her body and become passively permissive whenever her partner was interested in being sexually intimate with her. This was true even when she, too, was interested in being intimate. As an intervention, we explored how she might experience the original traumatic situation in a different way that incorporated her body. Through learning, among other things, a way to tense up her back muscles, open her eyes, and continue to breathe normally, she was able to remain in reality and to pull herself into the physical present when becoming aware of the pull toward her old, defensive behavior.