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Many people suffer from painful feelings about their own bodies. It’s an important thing to interrogate. We tend to blame our bodies for such feelings, but research has shown that attachment is closely associated with body image and dissatisfaction (Hui & Brown, 2013). Our body image develops through interactions with significant figures in our lives (Kearney-Cooke, 2002), and any body image issues tend to be sparked by early experiences of bullying, humiliation, and body image criticism by family members or peers (Boyda & Shevlin, 2011; Wolke & Sapouna,2008). Furthermore, an insecure attachment is associated with a greater investment in body image, greater dissatisfaction, and more negative feelings about the body overall (Cash et al., 2004).
ISTDP can help here, because it focuses on the causes of such issues by addressing attachment and our responses to it. This kind of work can facilitate a recognition of our conscious wish for affiliation and attachment with others, a conscious awareness of how we have learned to expect others to respond (Abbass, 2015) – and how we have learned to relate to ourselves as a result of this expectation. Abbass, A. (2015). Reaching Through Resistance. Seven Leaves Press: Kansas City, MO. Boyda, D. & Shevlin, M. (2011). Childhood victimisation as a predictor of muscle dysmorphia in adult male bodybuilders. The Irish Journal of Psychology, 32, pp. 105–115. http://dx.doi.org/10.1080/03033910.2011.616289 Cash, T. F., Theriault, J. & Annis, N. M. (2004). Body image in an interpersonal context: Adult attachment, fear of intimacy and social anxiety. Journal of Social and Clinical Psychology, 23, pp. 89–103. http://dx.doi.org/10.1521/jscp.23.1.89.26987 Hui, M. & Brown, J. (2013). Factors that influence body dissatisfaction: Comparisons across culture and gender. Journal of Human Behavior in the Social Environment, 23, pp. 312–329. http://dx.doi.org/10.1080/10911359.2013.763710 Kearney-Cooke, A. (2002). Familial influence on body image development. In T. Cash & T. Pruzinsky (Eds.), Body image: A handbook of theory, research, and clinical practice (pp. 99–108). New York, NY: Guilford Press. Wolke, D. & Sapouna, M. (2008). Big men feeling small: Childhood bullying experience, muscle dysmorphia and other mental health problems in bodybuilders. Psychology of Sport and Exercise, 9, pp. 595–604. http://dx.doi.org/10.1016/j.psychsport.2007.10.002 I am an able-bodied male-coded individual, and despite the fact that being able-bodied is in truth a transitory condition for every single person alive – that some form of disability awaits us all as we age (Potok, 2002) – ableism remains prevalent, a “common set of stigmatizing social values and debilitating socially constructed hazards” that disabled people have to live with and navigate that results in recurring experiences of “cultural devaluation and socially imposed restriction, of personal and collective struggles for self-definition and self-determination” (Longmore & Umansky, 2001).
The normative attitudes toward disability arise from the medical model which locates the disability in the individual (as a failure in their body) rather than in the failure of social structures to ensure accessibility for all. This is a capitalist logic at root, in that the cost of addressing disabled folks’ social marginalization and economic deprivation would be high, while their value to the capitalist machine, built as it is on the bodies of workers, remains low. And so we have the conception of disability as “pathological rather than political, clinical and not cultural” (Longmore & Umansky, 2001). The primary building block of this structurally oppressive edifice of thought seems to lie in the idea of normality - positing disability, or sickness, as a deviation from it (Baynton, 2001). This concept of normality is used to manage populations and situations, which brings us back to the present moment, one in which marginalized folks around the world were and continue to be disproportionately affected by the global pandemic, with people of colour the frontline workers among those most exposed, elderly folks in care homes a significant proportion of those tragically lost, and the disabled – which includes those who are immunocompromised and/or have what are known as “pre-existing conditions” – the most at continued risk. The vulnerable have been left to fend for themselves – with accessibility as high a priority for institutions as it ever was (meaning not very much at all). Herein lies the difficulty: it’s incredibly hard to convince people that they should care about other people. I may not be able to make anyone realize that it is good to care about other people, but I can certainly try to help people return to genuine care and compassion for themselves - in the hope that from such a place, genuine care and compassion for others might arise. With the well-being of my immunocompromised and high-risk clients in mind - as well as the basic issue of accessibility - I am therefore focusing on virtual (telehealth) sessions for now. If and when this changes, I am nevertheless decided to always retain this as an option for clients in the future. Baynton, D. C. (2001). Disability and the justification of inequality in American history. In Longmore & Umansky (pp. 33–57), p. 33. Longmore, P. K., & Umansky, L. (Eds.). (2001). The New Disability History: American Perspectives. New York: New York University Press, p. 12. Potok, A. (2002). A Matter of Dignity: Changing the Lives of the Disabled. New York: Bantam Books, p. 12. Cultural competence in therapy involves - but is not limited to - an awareness of someone’s country of birth, ancestry, their parent’s country(ies) of birth, languages spoken, Indigeneity, sexuality, gender expression, religion or spirituality, social behaviour and customs, physical and neurological differences, age and socio-economic status (Brooks et al., 2019). But such information is only useful if used to discover how an individual uniquely experiences these aspects of their identity (Dyche & Zayas, 2001).
Feminist and multicultural theorists indicate the importance of awareness and integration of the various intersections of a client’s identity to the development of an effective therapeutic relationship (Knox et al., 2003; Collins et al., 2010; Ecklund, 2012). Culturally competent therapy also requires a practitioner’s self-examination of their own reactions, a humility and openness to learning, the ability to use culture appropriately (and to ascertain when it is not related to the presenting issue), patience, empathy, and an awareness of the differential power status which, in cross-cultural therapy, can be significant (Dyche & Zayas, 2001; Yeung et al., 2018; Brooks et al., 2019; Lee & Neese, 2020). Awareness and incorporation of cultural differences in values, attitudes and behaviors (Interian & Díaz-Martínez, 2007) has been linked to better rapport, intimacy, disclosure, risk-taking, involvement, and therapy outcomes in marginalized clients (Henderson-Daniel et al., 2004; La Roche & Lustig, 2013; Graham-LoPresti et al., 2017). Treatment that fails to address contributing sociocultural factors in their lives may prove insufficient (Abrams, Hill & Maxwell, 2019). An exploration of intersecting aspects of a marginalized client’s identity, where relevant, and an awareness of the barrier to therapy different folks face, for example, may instead facilitate greater engagement among groups who often don’t get the support they most need (Abrams, Hill & Maxwell, 2019). As a member of such a group, and as someone for whom the idea of going to therapy was for the longest time simply unthinkable, I am determined to bring the healing power of this work to those so often failed by the mental health industry. Abrams, J. A., Hill, A. & Maxwell, M. (2019). Underneath the Mask of the Strong Black Woman Schema: Disentangling Influences of Strength and Self-Silencing on Depressive Symptoms among U.S. Black Women. Sex Roles, 80, pp. 517–526. https://doi.org/10.1007/s11199-018-0956-y Brooks, L. A., Manias, E. & Bloomer, M. J. (2019). Culturally sensitive communication in healthcare: A concept analysis. Collegian, 26, pp. 383–391. https://doi.org/10.1016/j.colegn.2018.09.007 Collins, S., Arthur, N. & Wong-Wylie, G. (2010). Enhancing Reflective Practice in Multicultural Counseling Through Cultural Auditing. Journal of Counseling & Development, 88, pp. 340-347. https://doi.org/10.1002/j.1556-6678.2010.tb00031.x Dyche, L. & Zayas, L. H. (2001). Cross-cultural empathy and training the contemporary psychotherapist. Clinical Social Work Journal, 29 (3), pp. 245–258. https://doi.org/10.1023/A:1010407728614 Ecklund, K. (2012). Intersectionality of Identity in Children: A Case Study. Professional Psychology: Research and Practice, 43 (3), pp. 256–264. doi: 10.1037/a0028654 Graham-LoPresti, J. R., Gautier, S. W., Sorenson, S. & Hayes-Skelton, S. A. (2017). Culturally Sensitive Adaptations to Evidence-Based Cognitive Behavioral Treatment for Social Anxiety Disorder: A Case Paper. Cognitive and Behavioral Practice, 24, pp. 459-471. https://doi.org/10.1016/j.cbpra.2016.12.003 Henderson-Daniel, J., Roysircar, G., Abeles, N. & Boyd, C. (2004). Individual and Cultural-Diversity Competency: Focus on the Therapist. Journal of Clinical Psychology, 60 (7), pp. 755-770. doi:10.1002/jclp.20014 Interian, A. & Díaz-Martínez, A. M. (2007). Considerations for Culturally Competent Cognitive-Behavioral Therapy for Depression with Hispanic Patients. Cognitive and Behavioral Practice, 14, pp. 84—97. https://doi.org/10.1016/j.cbpra.2006.01.006 Knox, S. Burkard, A. W., Johnson, A. J., Suzuki, L. A. & Ponterotto, J. G. (2003). African American and European American Therapists’ Experiences of Addressing Race in Cross-Racial Psychotherapy Dyads. Journal of Counseling Psychology, 50 (4), pp. 466–481. doi:10.1037/0022-0167.50.4.466 La Roche, M. & Lustig, K. (2013). Being Mindful About the Assessment of Culture: A Cultural Analysis of Culturally Adapted Acceptance-Based Behavior Therapy Approaches. Cognitive and Behavioral Practice, 20, pp. 60-63. doi:10.1016/j.cbpra.2012.04.002 Lee , H. Y. & Neese, J. A. (2020). Mental and Behavioral Health of Immigrants in the United States. Academic Press, pp. 157-178. https://doi.org/10.1016/B978-0-12-816117-3.00008-7 Yeung, A. S., Trinh, N-H. T., Chen, J. A., Chang, T. E. & Stern, T. A. (2018). Cultural Humility for Consultation-Liaison Psychiatrists. Psychosomatics, 59 (6), pp. 554-560. doi:10.1016/j.psym.2018.06.004 When I first arrived in this country I realized I had become complicit, just by virtue of my being here, in the ongoing genocide of the First Nations people that belong to this land. One of the reasons for my becoming a therapist was to make some kind of sense of my being here, on this land: the intention was, from the beginning, to ensure a significant percentage of my work is with the people who belong to this land – here in Vancouver, this primarily means the people of the Squamish, Musqueam, and Tsleil-Waututh First Nations.
Both sets of my grandparents were born colonized subjects, and I know all too well the internalizations that result; how heavy sits the Crown. I have to work in opposition to that; it’s the only thing that makes sense to me, to work with these and other marginalized populations and facilitate the undoing of the internalization of external forms of oppression, the undoing of all the frozen moments of trauma that creep into the body and contort it. Sadly, many of the systems in place that provide support to Indigenous folks also function under the oversight of the same enterprise that has its boot on their necks. Coping with the consequent feeling of incongruence this creates in me means keeping my eyes, ears and heart open in order to learn how this enterprise operates - so that I can make better decisions about how to be of service to this demographic and thus be a useful part of the healing journey being undertaken by the communities here. While I include feminist, existential, and client-centered thinking in my approach to the work of therapy, my focus is on the role of unconscious forces in an individual’s response to trauma. My belief is that all of us experience trauma, even if the worst thing we have experienced was simply the painful separation of birth itself. I believe that the ultimate goal of therapy is the removal of all obstacles to the processing of the emotions that are locked inside the body, whether these have arisen as an adult, perhaps due to systemic causes, or in early childhood, as a result of attachment trauma.
A vast majority of presenting problems in therapy can be traced back to - or can have some active component involving – attachment issues. Anxiety provoking emotional states are created in us as children when we experience obstacles to our innate desire to bond to a primary caregiver (Abbass, 2015). As adults we bring this early formation of expectation for other’s behaviour to our relationships; it informs how we view ourselves and also the form and expression of any psychological problems we might experience (Kernberg, 1980). While many of the strategies and coping mechanisms we develop in response to our early attachment experiences originally function as the best available option for survival when we are young, they can become the prime source of psychological suffering as we become adults (Abbass, 2015). They can cause somatic disturbances (Abbass, 2015), anxiety, depression, personality disorders (Abbass, Town, & Driessen, 2012), and interpersonal problems (Solbakken & Abbass, 2015). It is important to be clear that this is automatic and unconscious behaviour, not something we are actively choosing to do. Psychodynamic theory understands the unconscious as having a major role in internal conflict and pathology and maintains that a resolution can be achieved through the therapeutic encounter - through two equally meaningful presences in the room who both share a commitment to addressing the anxiety, defenses, resistance, and complex feelings that arise during the work of therapy. ISTDP therapy (Davanloo, 1990, 2000), focused as it is on attachment and an individual’s unconscious reactions to it, can facilitate an understanding of and healing from what often remains hidden from view because of the general focus we tend to otherwise have on dealing with symptoms rather than dealing with their causes. It makes sense that getting to the roots is the only way to ensure the weeds you want removed from your garden cannot return. Abbass, A. (2015). Reaching Through Resistance. Seven Leaves Press: Kansas City, MO. Abbass, A., Town, J. M., & Driessen, E. (2012). Intensive short-term dynamic psychotherapy: A systematic review and meta-analysis of outcome research. Harvard Review of Psychiatry, 20 (2), 97-108. doi: 10.3109/10673229.2012.677347 Davanloo, H. (1990). Unlocking the Unconscious: Selected Papers of Habib Davanloo, MD. John Wiley & Sons: Chichester, England. Davanloo, H. (2000). Intensive Short-Term Dynamic Psychotherapy: Selected Papers of Habib Davanloo, MD. John Wiley & Sons: Chichester, England. Kernberg, O. (1980). Internal World and External Reality. Aronson: New York, NY. Solbakken, O. A. & Abbass, A. (2015). Intensive short-term dynamic residential treatment program for patients with treatment-resistant disorders. Journal of Affective Disorders, 181, 67–77. doi: 10.1016/j.jad.2015.04.003 The suggestion that early childhood experiences shape adult functioning paved the way for attachment theory, which underpins the modern psychodynamic approach to therapy. John Bowlby (1958, 1969) developed attachment theory, maintaining that experiences with primary caregivers determined personality development, and Mary Ainsworth later furthered this work with her “Strange Situation” experiments (Ainsworth & Bell, 1970; Ainsworth, 1973).
In these, a child and its mother entered a room in which there was a person unknown to the child. The mother then left the child there, with the stranger, a situation a child would experience as dangerous. Their reactions were observed. After a few minutes, the mother returned, and observation of the child’s behaviour continued. The observed behaviours eventually led to the classification of four different attachment styles. Secure children would cry when left with a stranger, but then when the mother returned they would reconnect with her and would be soothed until they could self-regulate. Some children, though, seemed unconcerned by the mother’s departure - they acted as if the stranger (a real and present threat) didn’t exist, completely ignoring them, and then when the mother returned, would stay disengaged. These were described as insecure-avoidant. Others would cry when the mother left, but when she returned they could not be soothed by her, and were never able to self-regulate. These were described as insecure-resistant, or sometimes as insecure-ambivalent. The fourth kind would display odd, irrational behaviour when the mother left, like hitting themselves, and these were described as insecure-disorganized. Attachment theory went on to inform individual psychodynamic therapy approaches such as ISTDP (Davanloo, 1990, 2000), as well as both family and couples therapy approaches. Psychodynamic therapies such as ISTDP pay specific attention to the effect of early relationships with primary caregivers - to the child’s (sometimes pre-verbal) understandings and internalizations that resulted from these relationships, and how these manifest in individual attachment styles. These early patterns of relating to ourselves and to others can persist into adulthood, and go on to affect our lives and relationships. In extremely general terms, secure children often become autonomous adults, avoidant children often become dismissive adults, resistant or ambivalent children often become preoccupied adults, and disorganized children often become fearful adults. Why is any of this relevant to you? Because no matter what problems bring you to therapy, what is behind them, what is driving them, is likely something related to your relationship with others, and ultimately, to your relationship with yourself. Imagine a child who has been abandoned by one or both parents. Their unconscious, infant understanding of the situation may have led them to view themselves as somehow being repulsive - as having repulsed the abandoning parent. This might show up in adulthood as an impulse to please others for fear of ever being rejected again, or it might show up as a pattern of rejecting connection first before you yourself can be rejected once again. Your internal system – the way you make sense of the world and your relationships in it - might be centred upon the unconscious sense of somehow being less-than, of somehow lacking in inherent value. A person might respond to this by turning their feelings in upon themselves and becoming self-punitive, for example, or might turn their feelings outward, onto others, and become abusive. Attachment can thus be seen to have a very real effect on every aspect of your life, and without healing, perhaps through therapy, can also become generationally active - getting passed down in one way or another to your descendants. Ainsworth, M. D. S. (1973). The development of infant-mother attachment. In B. Cardwell & H. Ricciuti (Eds.), Review of child development research (3, 1-94) University of Chicago Press: Chicago. Ainsworth, M. D. S., & Bell, S. M. (1970). Attachment, exploration, and separation: Illustrated by the behavior of one-year-olds in a strange situation. Child Development, 41, 49-67. Bowlby, J. (1958). The nature of the child’s tie to his mother. International Journal of Psychoanalysis, 39, 350-371. Bowlby, J. (1969). Attachment. Attachment and loss: Vol. 1. Loss. Basic Books: New York, NY. Davanloo, H. (1990). Unlocking the Unconscious: Selected Papers of Habib Davanloo, MD. John Wiley & Sons: Chichester, England. Davanloo, H. (2000). Intensive Short-Term Dynamic Psychotherapy: Selected Papers of Habib Davanloo, MD. John Wiley & Sons: Chichester, England. Our personal boundaries are naturally occurring demarcations - between us and others, between okay and not okay - that we can become aware of by learning to listen better to the cues in our own bodies. Professional boundaries are different, of course, because they also take into account demarcations assigned by external factors or bodies - by the demands of a job, or an industry, for example.
In the context of psychotherapy, the relationships between client and therapist are vastly different to those we might have with our friends and family. The psychotherapy relationship involves the provision of a professional service, and a failure on either side to respect the unique set of boundaries that exist in this context will actively hamper the therapist’s ability to provide that service, and ultimately, their ability to help the client learn to sense, understand and enforce their own boundaries. If a therapist can’t walk the talk themselves, then what use is talking to them about walking, really? My personal history is the reason I became a therapist. My earliest experiences led to damaging internalizations which therapy was able to allow me to understand and to begin to heal from, and this same facilitation of healing is what I aim to bring to others. This impacts the way I approach therapy; I operate from a psychodynamic lens - the way of working which provided the best framework for understanding my own self. I bring the strength of my own experience as a client to my work - I have moved through that process all the way to the experience of love for myself, inside my own body. It was both a life-changing moment to feel this feeling, and one filled with grief - to realize that in all the years before that moment, I had not. I believe this is of critical importance for a therapist - to have been on the path too, in your own way, in order to be able to gently encourage others to traverse the path that lies before them.
I was a child of the South Asian diaspora, born in London, England, abandoned by my father and separated from my mother for long periods of time after she took me to live with my grandparents in another city while she returned to work in London. These early losses - of any genuine sense of a homeland, and of both parents - were bereavements to child-me. I was not to understand this, however, until forty years later - in therapy.
As a person of colour in the age of late stage capitalism, having lived the aftermath of the colonial experience, having undergone the emotional castration required of the male-coded by psychological patriarchy and then having found my way back to myself, to recovery and healing - and now, recognizing that there is work to be done out there, the work of healing, through therapy - I believe that this work is built upon the foundation of unconditional positive regard, for others, and for myself. Because without this unconditional love and compassion for my own self, what chance is there of putting its healing power at the service of others? Being grounded in a place of unconditional love and compassion for my own self is not and will never be a fait accompli, but instead is a continual doing, a lifelong practice to go hand in hand with the learning and doing of this other practice - of being with clients, in session. This lifelong practice touches each of the five domains of life: the physical, emotional, cognitive, social, and spiritual aspects of existence. For me, the emotional and the spiritual are all but the same thing, for feeling, as I have come to understand it, is the live wire, the manifestation of the animating force in all things, the current through which that most imminent of information - the life force itself - is carried. The physical, and the cognitive domains both, to me, reflect this central domain: the physical being the flip side of that same coin, the material manifestation - and the cognitive being the play of its shadow on the wall. As for the social domain, well - integrating this aspect has been integral to my journey. Once I began to understand the socio-political-historical context of my life, I discovered the harm that had been done to me and the harm that I was perpetuating. This understanding has taught me to walk the path with heart, by which I mean to walk the path with care - for myself, and for others. My intention now is centred around non malfeasance - to do no harm, to live an anti-oppressive life and to try to be a force for good in this world. This has entailed divesting from people and situations with and in which the barriers to living this way are too great. This has also entailed continuing to do the work of learning about such harms, in order not to perform them - to continue to hold myself accountable, to continue to learn about and engage with the political, and to understand through this how best to live with compassion for others. Living with care, both for myself and others, equates to living in accordance with my values. And living thus means feeling, for feelings are the information of living, and a heightened awareness of my feelings is a heightened awareness and connection - to life itself. Ultimately, all that any of us brings to our lives, our relationships, and our work - is our own self. Self-care, meaning self-awareness, is therefore a non-negotiable practice, without which we can be of no use to ourselves or to those we care about. But too many of us learn - often unconsciously and in response to painful experience - not to care for ourselves. We may have discovered that our own needs were not as important as those of the people around us, growing up – and therefore developed an internal way of operating that puts ourselves last. Therapy can be a proving ground – a space in which to learn about this unconscious system that causes so many different symptoms and difficulties, and a space in which to unlearn it. |
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