What Does a Session of Relationally-Oriented Integrated Therapy Look Like?

I’ll be honest, I’ve no idea what my 60 sessions of ‘Relationally-Oriented Integrated Therapy’ will look like – and my psychologist doesn’t really, either, as that’s sort of the point. We focus on the relationship, the many intricacies of what has built me/my struggles, and on what comes up in order to work on very broad aims rather than trying to rigidly follow a plan or methodology.

So, to give a bit of an insight into what a very early session of this therapy looks like in my case, I thought I’d share with you the notes that I wrote straight after this week’s session. I’ll warn you now, this was just stuff that I was writing verbatim after the session to help me process and retain what we talked about – it contains very little ‘content’ and mostly describes how the pair of us are trying to find our feet with each other and the therapy…so, in all likelihood, it won’t be the most interesting read! However, there is some discussion about the issues of perfectionism in therapy, complex trauma/PTSD vs personality disorder and the fight/flight/freeze phenomenon that may be of interest. I did also think it would be useful for anyone who is interested in or considering embarking on this type of therapy. Or it might just be rambling rubbish of no interest to anyone but me, which is also OK!

Throughout, my clinical psychologist will be referred to as R for convenience and privacy.

Excerpt from my journal: Session 3 of Psychotherapy

I actually managed to talk (a big surprise after a very hard last session, so much fear and catastrophising!). I managed to tell R what I’d been thinking and feeling about our session and therapy since last week. I explained that I’d had a total meltdown following the session, lasting for most of the week since, because I felt like I wasn’t doing ‘good enough’ because of the many and strong barriers in my brain; that to me that meant that I was never going to be able to ‘do it’, never able to do the intensive psychological work that I need to, never able to get better, and consequently not able even to survive.

We talked about why I felt that if something had gone wrong it would continue to do so, that problems were fixed and insoluble rather than something that we could work on and change: I explained that problems in my life had tended to remain incredibly fixed and permanent, that I hadn’t yet been capable of overcoming any big problems (objectively because I was ill-equipped and ill-supported, but in my reality because I’m just incapable, pathetic and useless). R explained that in her experience things can and do change, that there’s the potential for things to be fixed, and that she sees me as someone very willing to put that hard work in to make those changes.

R said that she felt like what was happening was a hell of a lot of fear and asked if I knew what happened when we felt a tremendous amount of fear – I said the fight or flight response, and also the more recent 3rd option: freezing, which is the one that I suffer with to an extreme extent. R asked me to think about how awful and terrifying experiences must be for any living creature to become so overwhelmingly afraid that it can’t even take an instinctual action to to fight or fly – for the only option left available to it to be to freeze. Independently we both imagined a small mammal in this situation, then shared our thoughts and visualised it together; R asked me how I felt about the little mouse who is so terrified that it’s frozen: I said that I felt sad for it and would want to comfort it…then laughed and told R that I wasn’t going to be tricked into thinking those things about myself! She explained the 3F responses further, that the part of the brain responsible is right at the very top of the brainstem so kicks in before anything else has a chance to even know what’s going on – so the freezing that I’d been beating myself up for as inadequacy isn’t a conscious or even a necessarily controllable decision – it’s not about not trying; it does, however, stop us processing, analysing, contrasting, connecting and in severe cases even being aware of our thoughts, feelings and experiences. She said that she could see that there were a whole raft of ‘buts’ there in my head and asked what those were: I said that I should be better equipped than a mouse to deal with this sort of thing, that I wasn’t deserving of kindness/support/soothing, and that I still didn’t believe myself to be a real human or…as we were now using a mouse metaphor…even a real animal…I must be the equivalent of a plant, so all of that stuff doesn’t apply. R explained that, actually, humans are less equipped than animals because as well as the mammalian brain we have the front brain which adds in all of this self-analysis, complex thought, reflection, thinking about the future etc…so actually it’s harder for a human to deal with all of this than a mammal. She then said that these ideas about worth or humanity are so fixed that it’s going to take a lot of hard work to get over…but even if she rolls with the plant metaphor (and she can use any metaphor I throw at her!) then she could even help to nurture, nourish and grow a plant if it came to it!

We talked about what it was about last week that I felt had gone wrong and why that felt unchangeable. I explained that it was the freeze response – she asked how that feels/presents iteself for me – I explained that sometimes it means that I just can’t make myself talk/voice any kind of thoughts/feelings (even the fact that I’m struggling to talk) and sometimes it stops my awareness of the thoughts/feelings entirely…that then stops me being able to say, do and work on the things that I need to…which in turn makes me feel hopeless as I know that it’s vital for me to do this work. She suggested that I then might feel some rejection because of this especially with my past experiences, which I confirmed, and said that I also felt like I needed to prove myself to her…something that I was failing to do to my own standards. R raised that it must be hard for me as I can’t work within the normal parameters of achievement in therapy, and particularly in this type of therapy, and that that’s something very troublesome for me as I need to do everything perfectly and be able to work hard on something until it is done to a tangible very high standard…that this just can’t happen in this situation and it is likely to cause a lot of turmoil and distress. I then kind of when on to prove her point by asking what I needed to do to overcome this immensely powerful reaction and she said that actually it would likely involve learning to soothe myself and show self-compassion rather than trying to bulldoze through the reaction, a slower process but the only real way to get over this when it is so strong and so ever-present.

R raised that she thought it was really interesting that, having left the session upset and scared that it wasn’t working and could never work, I turned the responsibility of that in on myself entirely and completely, without hesitation – I didn’t blame the ‘bad therapist’ or the ‘bad therapy’ or even the bad circumstances, not even to a small extent – the blame was all mine, and was applied very harshly. She said that she thinks that this probably goes on in all areas of my life, which I confirmed. She said that I need to use her and lean on her, undertake this as a joint venture, see her as a partner in this journey with just as much responsibility as me, but that she knows that this is an entirely new situation for me that must feel terrifyingly impossible.

I explained that I have a complete preoccupation with wasting her time and that that plays into the mix, as well. She laughed and said that she was paid for this after all! Then said that, in all seriousness, if she thought I was wasting her time/not trying/not being committed/not doing my best then she would tell me, and we would sort it out, but that she highly doubts that – from what she already knows of me and due to the nature of this type of therapy – that situation would ever occur. She asked what it is I thought would happen if I was wasting her time: I said that I would be rejected, that treatment would stop and consequently I wouldn’t be able to get better…which would mean continuing to live in this torture or, more likely, giving in. She said that this fits with my past experiences and is entirely understandable but asked if there was a different way to look at what happened last week, and what it might mean…I said that lots of professionals had told me their differing views to mine…she asked if I could come up with any. I said that, objectively, I imagine she expected something like that to happen – R nodded knowingly and asked if there was anything else that might have come out of it. I said that the fact that it happened could bring up important stuff that needs to be addressed and worked on – she fervently agreed and said that it’s actually really important because now we are acutely aware of these visceral fear responses that I have to certain things, and we know that we need to work on those things and she can now try to support me through that.

R asked in what circumstances these freeze responses tend to happen: I responded that, outside of that room, it happens at almost any time that attention or conversation turns to me, or whenever I show emotion or express feelings – but that inside this room it seems to be when we look at the deeper stuff, at things I haven’t explored before, at things mostly under the surface of the ‘illness’, or especially when there is discussion or anything that vaguely resembles past traumatic treatment. She agreed and said that it’s truly astounding how strong my fear response to these things is but that these are the things that we can now work on and she wants me to know that we really CAN work on them.

R then went on to explain how, although the umbrella diagnoses in personality disorders are there because of a combined set of symptoms, what lies underneath for me and for many people with debilitating personality disorders is actually a set of very compounded complex traumas, starting from a very young age, triggered and reinforced repeatedly and based on a whole range of issues throughout childhood, adolescence and life. And it’s those causes – that deep, complicated, messy, terrifying stuff – that we need to work on, not just symptoms or through rigid, standardised treatments. Here I said that I didn’t think that I’d been through anything bad enough to warrant this, that it was just me being pathetic, and she interrupted me with a *common misconception claxon* saying that, because this was my life combined with harsh self-judgement, I couldn’t look at it and see the many layers of complex trauma and horrific circumstances that I’d endured; however just from what she knows from the assessment process my situation certainly strikes her as one of repeated complex trauma, and that she actually expects more become apparent as we work together. She admitted that this means that our work will be very hard and destabilising, and will mean that I will have to endure and sit with not only the emotions that I already feel so strongly but also all of those that I’ve suppressed for my entire life – and that will be incredibly, incredibly hard. We will probably end up finding many different strands of a tapestry, trying to weave them together, leaving some loose ends quite uncomfortably that we can’t come back to until a later date, sometimes creating what appears to be completely separate tapestries – and all of this is likely to happen painfully slowly and in a very non-linear way, that might feel disjointed and confusing and frustrating slow. I said that the problem was that I’d feel like I’d need to weave it all together and present her with finished pieces between sessions – berating and punishing myself massively when unable to do so – which she gave a knowing laugh at and said that this is where it’s going to be especially tricky for me because I need to let her hold some of this stuff for me for the first time in my life, and accept that this is something that I can’t and shouldn’t have to do on my own – I don’t need to (and won’t be able to!) leave a session and then come up with an outstanding solution to the problem, get full marks and then continue work…that’s not what therapy about, isn’t what life should be about, and certainly isn’t what she’s about.

Congratulations if you made it to the end of my rambling summary! As I said, it was written for myself, so may be of little interest to anyone else and certainly had no style or explicit aim to entertain/inform at time of writing. I’m sharing it in the hope that it just might be interesting to someone out there though, knowing how much I would have liked to read a bit about experiences of this kind of therapy, and of how to ‘do’ therapy (surprise: there’s no right way to ‘do’ therapy!!).

One thing I’m certain of: I’m very lucky to have such a knowledgeable, robust and flexible clinical psychologist willing to challenge the norms accepted by the system/her colleagues and work in the way that she feels is right for the individual in front of her: not squeeze people into often inappropriate diagnostic boxes that are then used to entirely inform very rigid treatment plans. I feel sure that I am ‘Molly’ to her, and that it’s ‘Molly’ that she’s working with, not a list of diagnoses and symptoms.

This could work.

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