Most patients quickly take to imagery. They easily produce clear images and carry on dialogues, become involved with them on an affective level, and require minimal prompting and assistance. However, a significant minority of patients needs more assistance: Their images are vague, sparse, or nonexistent, or they seem emotionally detached from their images.
Schema avoidance is the central obstacle to doing experiential work. Imagery work is painful, and many patients act automatically and unconsciously to avoid that pain. They close their eyes and say, “I don’t see anything,” “I only see a blank screen,” “I see an image but it’s vague and I can’t make it out.” The therapist can use several strategies to overcome schema avoidance.
Imagery work evokes painful affect, and the patient needs a good reason to endure it. When patients avoid doing experiential work, we first make sure that they understand the rationale. We present all the advantages. We contrast intellectual understanding with emotional understanding and tell patients that experiential work is most potent in fighting the schema on an emotional level. We explain that schemas change more quickly when patients relive their childhood experiences in imagery. We tell them that, until they do the experiential work, they will still believe that the schema is true. We empathize with the fact that experiential work is difficult, but we point out the costs and benefits just the same.
The next option the therapist has is to wait.
THERAPIST: Close your eyes and let an image from your childhood float to the top of your mind.
PATIENT: I’m trying, but I don’t see anything.
THERAPIST: Don’t worry, just keep your eyes closed. Something will come (long pause).
PATIENT: I still don’t see anything.
THERAPIST: It’s okay to take your time. Take five minutes if necessary, and let’s see what comes. Even if nothing comes, it’s OK.
The therapist can also give the patient permission to generate any image at all.
THERAPIST: It doesn’t matter what kind of image it is. It doesn’t have to be real. It can be a fantasy. It can be colors, shapes, lights.
Sometimes the combination of the therapist’s permission and a few minutes of time is enough, and the patient finally produces an image. However, when this does not work, there are other options.
Another way to counter schema avoidance is to begin with a safe-place or other relaxing image and then gradually introduce elements that are slightly more threatening. This is a kind of graduated exposure which contains a hierarchy of characters and situations, and the therapist introduces increasingly more threatening characters and situations as the imagery progresses.
For example, the therapist might start the patient with a safe-place image, then bring one of the patient’s close friends into the image, then bring in the slightly more problematic lover, and finally bring in the even more problematic father. The therapist might take several sessions to do this, exploring each step fully with the patient before moving on to the next one.
Sometimes patients are too depressed or labile to handle the imagery work: The imagery work activates powerful emotions, and it is hard for the patient to shake free of these emotions after they leave the session. Their emotions feel scary and unmanageable to them. This often happens to traumatized patients. Sometimes medication can help contain the affect so these patients can continue with the work.
One danger is that the medication can diminish the affect so much that the patient becomes numb and cannot do the exercises. The goal with medication is to reach an optimal level of arousal at which patients can still feel emotion but not so strongly that they feel unable to cope. If patients are too highly aroused, they feel too overwhelmed by the experiential techniques; if they are not sufficiently aroused, they are unable to generate enough affect to benefit from the techniques.
When patients have difficulty feeling or expressing emotion, the therapist can sometimes help by focusing them on their bodies. The therapist can add sounds or motions to the feeling. For example, the therapist can tell patients to speak more loudly or to hit a pillow while attempting to express anger; or the therapist can instruct patients to assume certain positions, such as a fetal position, an open position, or a trapped position.
For example, in the preceding illustration with the patient Daniel, when the therapist encouraged Daniel to express his anger at his sexually abusive mother, the therapist could have instructed him to pound a pillow or the couch with his fist as he spoke to her.
Another option is for the therapist to open a dialogue with the part of the patient that is avoiding. We call this part of the patient the Detached Protector mode. We elaborate on this mode in greater detail in Chapter 8. However, here we briefly illustrate this technique as a means of overcoming schema avoidance. The therapist speaks directly to the part of the patient that is avoiding feeling or expressing the emotions connected to the imagery, the Detached Protector. Until we speak directly to the Detached Protector, we usually do not know why the patient is avoiding, and we therefore have difficulty finding a way to overcome the avoidance. Once we speak to the Detached Protector, we can usually find out why the patient is avoiding, and then devise a plan to overcome it.
Here is an example with Hector, the 42-year-old patient we described previously whose mother was schizophrenic throughout his childhood. Hector is doing an imagery exercise in which he is visualizing himself as a child with his mother. In the image, his mother is sitting next to him on a bus, loudly talking about “traitors.” The therapist is trying to get the child to vent anger at his mother for embarrassing him in the image, and Hector is resisting. The therapist initiates a dialogue with the Detached Protector.
THERAPIST: Little Hector is so angry and he wants to express it. Why won’t you let him express his anger? Be the side of you that wants to stop him from showing anger.
HECTOR: (as Detached Protector) “Well, what if Little Hector feels it, what can he do about it anyway? There’s nothing he can do anyway, so what good is it for him to feel it?”
THERAPIST: Well, the value is that now we’re here to help him, and we can protect him, and it’s safe for him to express his anger. He has a right to feel his anger. He has a right to express his anger.
HECTOR: What if he goes out of control? What if he goes out of control and hurts someone?
THERAPIST: Has he ever done that? Has he ever gone out of control and hurt someone?
HECTOR: No. Never. I mean, not more than to yell at someone.
THERAPIST: How about if we try an experiment? How about if you try letting him express a little bit of anger and see how that feels? See if he feels better.
HECTOR: (pause) OK.
Until we understand why the patient’s Detached Protector mode is interfering, we do not know how to respond. Once we give the Detached Protector a voice, we can learn why the patient cannot feel or express the emotion. We then are able to reason and negotiate with the Detached Protector.
We discuss this type of mode work further in this book. However, this example shows one way in which mode work can be helpful. By taking an avoidant coping style and making it into a mode, we give it a voice to which we can speak and with which we can negotiate.
If, after all this work, patients still insist that they cannot do imagery, we try one last technique. We tell patients that an overwhelming percentage of patients who say they cannot do imagery actually are able to. We then ask them to try an experiment: to look at the therapist for a full minute, then close their eyes and try to picture the therapist in an image. Almost all patients say they can see the therapist. This experiment illustrates that most patients are capable of seeing images. It is the Detached Protector who is stopping the patient from seeing them.