Jennifer Bulow dissertation

The Institute for Clinical Social Work

Therapist Experience: Re-Envisioning Politics in Psychotherapy

A Dissertation Submitted to the Faculty of the Institute for Clinical Social Work in Partial Fulfillment for the Degree of Doctor of Philosophy

By Jennifer Bulow, LCSW

Chicago, Illinois July 27, 2019

Abstract

This qualitative research study explores therapists’ personal and professional experiences and clinical exchanges regarding “politics� in psychotherapy. The overarching research question considered how therapists respond to, work with, and conceptualize political material that emerges in psychotherapy sessions. The findings show that heightened external circumstances do impact psychotherapy and the therapist, ultimately enhancing therapist growth and development. Since 2016, the frequency and intensity of political material in psychotherapy sessions has increased. This study finds that sharing in a collective, and at times, traumatic and dysregulating external sociopolitical reality, challenges therapists to grow professionally and personally by increasing authentic, spontaneous responses which enhance closeness and attunement, from the perspective of the therapist. Therapists do consider both the inner-psychic world, as well real-life considerations, relationships, and impacts when they think about their clients and a relationship to political material. The participants used the interview process to reflect upon their own relationship to the political, including personal political participation, therapeutic interactions, and how the puncture of the therapeutic space by the outside world impacts their own thoughts, feelings and clinical interventions.

2

For Ken, Olivia, Isabelle, and my parents

3

The profound consequentiality of everyday life—the ways in which it not only reflects the dynamics of the internal world but also creates them—is lost when everyday life is not treated in the same fully relational manner as the analytic relationship; that is, as the dynamically alive and continually evolving response to an intersubjective process shaped by the participation of the other as well as by the already existing characteristics of the self. ~P. Wachtel, 2017

4

Acknowledgements

I am grateful to Dr. Samoan Barish who guided me with creative and innovative thinking through this dissertation process, with the constant reminder to note the ways in which I was growing personally and professionally. I am deeply appreciative to Dr. Judith Schore for her constant support, generosity, and honest feedback. Learning from Dr. Schore has updated my knowledge about theory, creating a stronger base for the core of my practice.

Dr. Mary Coombs and Dr. Susan Spiegel’s creative mentorship, and feedback throughout the PhD program helped me find my voice. I am so grateful for the many remarkable Sanville students that I worked with over the last few years. I am thankful to the Sanville Institute for many years’ of connection and to ICSW for offering a home for the final months of this dissertation process. Thank you to Dr. John Ridings and Dr. Jacquelyn Vincson at ICSW for participating in this process with me. And, thank you to Professor Andrew Samuels for the meaningful contributions to the subject that I endeavor to add to, and participation in this scholarly effort.

I would also like to acknowledge the important contributions of my research participants. I am grateful to them for sharing their time and experiences with me.

And finally, to Dr. Elaine Leader, whose trailblazing career as a social worker has set a bar worth following.

JLB 5

Table of Contents

Page Abstract..............................................................................................................................ii Acknowledgements............................................................................................................v Chapter I.

Introduction............................................................................................................1 Statement of Project Intent Description of the Problem and Background Research Question and Design Theoretical Framework Definition of Concepts Significance of the Project

6

Table of Contents—Continued

Chapter II.

Page

Literature Review................................................................................................24 The Beginnings: Freud, Power, and Politics Theory Relational Theory Concepts in Relational Theory Self-Disclosure How Therapists Conceptualize and Respond to Politics Neurobiology and Affect Regulation Shared Reality and Trauma, Collective and Shared Traumatic Reality Impact on Clinical Social Work and Posttraumatic Professional Growth National Trauma and Cultural Trauma Current Events and Political Reality Previous Research

III.

Methods.................................................................................................................81 Methodology and Design Participants and Sample Data Collection Data Analysis Limitations and Validity

7

Table of Contents—Continued

Chapter IV.

Page

Findings.................................................................................................................91 Review of the Methodology Participants Overview of Findings Finding I: The Personal Perspective Finding II: Therapeutic Engagement in a Special Circumstance Finding III: Shared Reality Finding IV: Growth and Development

8

Table of Contents—Continued

Chapter V.

Page

Discussion...........................................................................................................128 Overview of Study A Note about Historical Context Bias Personal Perspective and Participation Therapeutic Engagement in Special Circumstances “It’s Much More Common to Be in the Room Now” “Intrapsychic Stuff Also while We Process this World” Shared Traumatic Reality and Collective Experience “We’re in This Together” Shared Reality Creates Opportunities for Growth Development Final Thoughts Limitations Recommendations for Further Study Contributions to the Field of Social Work Conclusions

9

Table of Contents—Continued

Appendices

Page

A. Sample Recruitment Letter...............................................................................184 B. Advertisements and Posts for Recruitment.....................................................186 C. Sample Letter/Email to Prospective Participants...........................................188 D. Prospective Participant Questionnaire............................................................191 E. Sample Letter/Email for Prospective Participants not Accepted for Study 193 F. Sanville Institute Informed Consent................................................................195 G. Cover Letter for Re-Consent of Participants for ICSW Program................198 H. Institute for Clinical Social Work Research Information and Consent for Participation in Social Behavioral Research...................................................201 I. Interview Guide..................................................................................................205 References.................................................................................................................208

x

1

Chapter I

Introduction Statement of Project Intent This qualitative study used grounded theory to explore therapists’ experiences and clinical exchanges regarding political material in psychotherapy. The multi-pronged research questions asked how therapists respond to, work with, and conceptualize political material that emerges in psychotherapy sessions. The intent of the project was to explore the therapist’s personal and professional relationship to what they consider to be political. Through the therapist responses and reflections, this research offered an opportunity to recognize and discuss the meaning and impact of clinical interactions surrounding the political, particularly considering recent current events. Internal and external experiences are constantly influenced by the environmental, interpersonal, social, historical, and political context that surrounds an individual, and thus the external shared reality of therapists and clients influence the subjectivity they bring into the therapeutic space. Impacts of man-made and natural disasters are noted in the literature but, little attention is paid to the effects of a shared cultural trauma and heightened sociopolitical events on the psychotherapy process. “Our inner worlds and our private lives reel from the impact of policy decisions and the existing political culture” (Samuels, 2015, p. 2). The current environment has been and continues to be one in which news and

2 events in the political realm and socio-cultural issues are tinged with heightened, impassioned, and strong ideological reactions. The impact of social media, news, and technology has led to exposure and over-exposure, which can be dysregulating, exhausting, exciting and in some circumstances, upsetting, overwhelming, or traumatizing. How do clinicians typically feel they interact with “the political?� What happens when both members of the therapeutic relationship are interacting with a challenging external shared reality in the political realm? And, in such circumstances, how and in what way does the impact of that external political reality present in the psychotherapy hour and how do therapists respond? This study intended to use qualitative research to begin to discuss and make sense of the therapist’s experiences with the puncture of the political into the psychotherapeutic space.

Description of the Problem and Background In my psychotherapy practice it has always been commonplace for my clients to talk in session about issues that concern policy, economics, gender, class and race directly and indirectly. This has been the case for as long as I can recall. However, beginning in the summer of 2016, I began to observe that the regularity, depth, and heightened affect related to this subject rose exponentially. This coincided with remarkable external newsworthy occurrences; the presidential campaign, election, inauguration, and ongoing news of the current presidential administration, as well as incidents of racial violence, mass trauma, natural disasters, policy changes, and political activities and protests.

Simultaneously, I too was being impacted personally by similar events and themes in an amplified way. My personal reactions to the same external socio-political reality as my

3 clients contributed to a heightened sense of shared experience and mutuality within the therapeutic relationship that felt different and unique for me. Sociologist, Neil Gross (2016) asked if, following the election, some were experiencing a “collective trauma.”

Arthur Neal’s definition of national trauma may be applicable here: A national trauma involves sufficient damage to the social system that discourse throughout the nation is directed toward the repair work that needs to be done.

The integrity of the social order has been called into question, and shared values are threatened. The disruption may take the form of a threat of foreign invasion, a collapse of the economic system, a technological catastrophe, or the emergence of rancorous conflicts over values, practices, and priorities. Whatever form the trauma takes, a significant and deplorable departure from the normality of everyday life is in process. (Neal, 1998, p. 5) During that time, my clients wondered more explicitly about my responses and reactions to this shared reality, and I began to wonder if other therapists were experiencing similar questions. If so, how were they responding to their clients? How much self-disclosure was occurring between other therapist/client dyads? And how were other therapists conceptualizing this phenomenon? Thinking about neurobiology, implicit right brain affective communication, and therapist subjectivity and self-disclosure, I considered what the impact of national trauma might be on the therapeutic relationship.

How were therapists responding to clients when their ideology, experience, and reactions to the shared reality were not aligned with their client’s?

In the journal, Psychoanalytic Dialogues, Seligman, Ipp & Bass (2017) wrote an editor’s introduction which highlights that I was not alone in my questions and concerns:

4 Many of us have been experiencing the effects of this collective trauma, living and working in states of distress, disbelief, fear, shock, and despair, even as we attempt to help our patients cope with the effects of the collective trauma that we now share on their personal efforts to use therapy to cope, to change and to grow…This seems unprecedented in our experience as therapists (Seligman, Ipp, & Bass, 2017, p. 111-112).

It was this sense of an unprecedented experience that created an important opportunity for further research about this phenomenon.

Nancy Chodorow (2002) highlighted, “that history affects people psychologically no less than it does physically and materially, and that this psychological impact is registered emotionally and unconsciously as well as consciously and cognitively” (p.

298). The impact of socio-political concerns on individuals’ inner life and physical and social reality is undisputed, however questions about how, when, in what way, and to what end therapists interact with these issues directly with clients has continued to be the source of much discussion (Avissar, 2016; Layton, Hollander, & Gutwill, 2006; Ru`derman & Tosone, 2013; Samuels, 2004).

The legacy of psychoanalytic theory includes an expectation that therapists maintain an apolitical stance with clients (Botticelli, 2004; Cushman, 1995, Seeley, 2005). Objections to the integration of “the political” into therapy include fear that it may not be sound clinical practice to move the focus away from the internal world, a suggestion of a lack of neutrality on the part of a therapist, and concerns about the slippery slope of what might occur if a therapists/client holds opposing views on policy or politics (Avissar, 2016). Avissar (2016) notes that in the late 1980s, “this process of

5 repression of the political gradually began to fade” (p. 19) possibly in response to the emergence of relational and intersubjective theories (Stolorow & Atwood, 1993; Greenberg & Mitchell, 1983; Benjamin, 1988, 1995) and their focus on multiple subjectivities and a two-person psychological system. These theoretical developments opened the door for the psychoanalytic field to inquire about differences and similarities between therapists and clients including issues of race, class, gender, and culture (Altman, 2010; Layton, 2006; Suchet, 2007).

Current political context.

A taxing socio-political environment impacts everyone, despite personal ideology.

Periodicals and academic literature has begun to document a higher incidence of political material making its way into therapy. The opening statement of a New York Times article from October 2016 titled, Talking to Your Therapist About Election Anxiety, notes, “It has been described as one of the most contentious, tawdry, and angry presidential elections in history. And it’s taking a toll on our mental health” (Alderman, 2016, para.1). Psychiatrist and trauma specialist, Judith Herman co-authored an Op-ed piece pleading with elected officials to “protect us from this dangerous president (Herman & Lifton, 2017, para. 5).

She and 26 other psychiatrists and mental health professionals contributed to a book, titled The Dangerous Case of Donald Trump (Lee, 2017), which discusses the seriousness of the risks and concerns raised by the current president. In this volume, Panning (2017) outlines what she calls, Trump anxiety disorder, “feeling a loss of control; helplessness; ruminations/worries, especially about the uncertain sociopolitical climate…excessive social media consumption…

6 polarization…divide between families and friends of differing political beliefs” (p. 237).

With a seeming rise of conversations in therapy offices focusing on the election and postelection consequences, questions about therapist responses, self-disclosure and shared experience should follow (Lyford, 2017; Guralnik, 2016, 2017a, 2017b; Burnett-Zeigler, 2016). Panning (2017) notes that therapists too, are struggling with the same anxieties as their clients. Websites and groups for therapists began to promote the ethical discussion of politics in the therapy hour (www.citizenstherapists.com, www.psychanalyticactivist.com). Email and listserv groups for professional mental health associations gave voice to an array of opinions (AAPCSW Google groups, NASW Facebook page). This is not the first time social, historical and political aspects of the environment have intruded upon the mental health and well-being of individuals. The September 11th attacks, natural disasters like hurricane Katrina, the Gulf War, police and racial violence, and policy issues around LGBTQ issues, and healthcare are referenced in psychotherapy literature. History offers no shortage of conflicts, newsworthy events, issues, and policies that have intersected with personal intrapsychic issues, influenced well-being, and provoked response.

The American Psychological Association (APA) national survey reports Americans’ stress levels changing course in 2017 (American Psychological Association, 2017). In 2016, the APA added election related questions to their survey in response to therapist reports that clients were increasingly anxious and worried about the political situation. The January 2017 report found, “more than half of Americans (57 percent) report that the current political climate is a very or somewhat significant source of stress”

7 (American Psychological Association, 2017, p. 1). According to the survey, the stress spans across the ideological spectrum and represents all political parties. Fifty-nine percent of Republicans surveyed reported the “future of our nation was a significant source of stress for them” (American Psychological Association, 2017, p.2). Top areas of worry for Americans included terrorism, police violence towards minorities, gun violence, the economy, money, personal health, and health concerns with family members. Layton, et. al (2006) writes in the introduction to a volume dedicated to politics and class in psychoanalysis, “A traumagenic environment is constituted when individual and group physical safety, social security, and symbolic capacities are all simultaneously assaulted” (p. 3). She goes on to elaborate that therapists are in an integral position to work with the “interpenetration of subjectivity and the sociopolitical order” (Layton, 2006, p. 2). This research aimed to consider such an overlay in its discussion.

Clinical experiences.

The APA survey (2017) was consistent with the worries and issues my private practice clients were presenting in their sessions. Many of my clients expressed higher stress, fear, anxiety, anger and frustration before, during and after the election, which highlights a lack of diversity in my practice. On the eve of the election, I received a text from one particularly distraught client, “I don’t know if I can handle this,” and in following days, messages from others, “I think I need to make an appointment to come in because I can’t talk about the president with my family… I feel like I’m falling apart.” I understood the sense of shock and trauma being expressed as I was coping with similar distress, worry, disappointment about the current political realities.

8 I listened to stories of people doubly impacted by experiencing the anxiety of others in combination with their own, often seen as secondary traumatic stress. My brother, a middle school teacher, offered support for his students while the teens expressed distress and fear of changes in immigration policy, LGBTQ rights, and health care access. At that time, he described himself as traumatized both by his own shock of the election results but also in his role as teacher as he was absorbing his students’ panic and fear. Because of his own stress, he texted his therapist outside of their therapy hour for the first time. This highlights the multiple layers of collective experience and exemplifies the role therapists may have played for others. Some colleagues shared with me that the day after the election they felt a shared grief or disappointment, but this was not everyone’s experience. What about the dyad who did not share ideology? One colleague shared with me that in her first session the morning after the election, her client came in pleased with the result, in conflict with how the therapist was feeling. Curiosity about how therapists managed those differences in the moment and over time, and its impact on the therapy relationship is a question this research looked to begin to answer.

Case examples: Uniqueness of “the political” in therapy.

Variety in my own clinical experiences left me with lingering questions and curiosity about the ways politics and political issues present in therapy, their impact on the process and relationship, and the various ways clinicians think about the interaction between intrapsychic and environmental factors. Two very different clinical experiences highlighted some of the unique ways politics may emerge in treatment and explain why I became interested in exploring questions about politics in psychotherapy.

9 Brandon was raised in a “red” mountain state by a highly conservative family. His own liberal beliefs and strong views left him feeling like an ideological misfit from his family. Brandon’s early relational traumas and problematic attachments impacted his current emotional state, leaving him suffering from debilitating depression. Wellness and individuation from his mother potentially came at a great cost, leaving him feeling deeply disconnected from a sense of aliveness. After Brandon’s mother passed away he faced a dilemma. For Brandon to be alive, grow, or develop meant letting go of the flat underdeveloped parts of him that continued to keep him bound to his mother, even after her passing. This resulted in deep depressive episodes for Brandon, complicating his grief.

Brandon’s mother worked in the public sector thus he grew up immersed in politics.

They would engage in long, intense, enlivened conversations about politics and this was one of the most individuated aspects of their relationship. Brandon spoke with me in session about politics prior to his mother’s death. We spent time in sessions exploring his reactions to Donald Trump, as Brandon expressed concern that he could relate to what he described as Trump’s narcissism, a deep sense that others would never meet his needs.

We used this as an opportunity for us to talk about neediness and shame, manipulation, trauma, and gratification of desires.

After his mother’s passing, and as the election cycle became increasingly acrimonious, we began to discuss politics in a unique way that was different from any other client. In session, he was either so stricken, depressed, and overwhelmed by his “not alive” state that he could barely participate in therapy, or he discussed politics, in which a more enlivened, engaged Bandon would interact with me. Brandon was

10 opinionated and highly intelligent. As he sought to engage with depth around sociopolitical issues, I reciprocated with spontaneity and authenticity, noting an implicit and explicit acknowledgement of the real shared reality and some similarities in our world view. These discussions included revealing aspects of my opinions and perspective with a genuineness and thoughtfulness. Discussing politics for Brandon was a distraction from his depression and grief. It was also comforting, familiar and safe because it was similar to how he might interact with mother if she were alive.

By engaging in provocative and engrossing conversation about politics I offered a different part of myself to Brandon in terms of the use of self-disclosure, boundaries and intimacy. The political material was a counterweight in our therapy; it appeared to pull him out from his despair by its interactive, “alive,” heated, provocative nature, even if it was only for an hour. At the time, I felt that our political discussions allowed me to interact with his aliveness. He could become excited, creative, and engrossed during session as opposed to flat, or lifeless. I have thought about how I may have relied upon and participated in those interactions because it was a relief to be with him when he was “alive.” And, I have wondered if our engaging discussions created a secondary gain in me; regulating my own system by sharing in outrage, disbelief, shock and frustration about a common socio-political reality and collective experience.

Of course, not all clients have spent time in therapy discussing politics, and those that do each present the subject in their own way. Another client, Greg, intensely followed the political scene by reading the news, watching TV, and receiving constant alerts on his phone. He brought this up in session regularly. However, my responses and

11 the way I thought about the use of politics with Greg differed from my experiences with Brandon.

Greg was highly anxious, sensitive, and often felt easily injured by interpersonal interactions. We worked together on his feelings of abandonment and rejection for many years. Greg often sought to engage me to reveal a “similar feeling” about some external (non-political) situation. Greg’s high anxiety was heightened and intensified by the political and current events. During the election he expressed increased fear, worry and a developing need to protect himself. Occasionally, in session, it felt as if he wanted or needed me to share and match his anxiety by disclosing my own. He was generally aware that I shared some of his views, but I did not talk about my own personal perspective in depth on purpose. Greg’s views were more extreme than my own, and seemed to be tied to anxieties that I do not share, and I was less comfortable being revealing with him. I suspect he was hoping that by experiencing my dysregulation, it might justify his worries and help him to feel less alone. I felt stuck and withholding as I attempted to tow a line between acknowledging the reality of the challenging environment outside of the therapy and holding the frame that seemed indicated. I was worried that by being withholding, Greg was left abandoned in his anxious state.

Not too long after the election, Greg terminated our work to meet with someone for medication management only. While the relationship ended on good terms, I have continued to question how I used and responded to the political content. I wonder how my reactions to and boundaries around the political discussion in session limited me from containing or acknowledging his anxiety. Were my choices deleterious to the treatment?

Was I experiencing the current political events in such a heightened way myself that my

12 ability to create enough space for my clients was limited? My clinical experiences with Brandon and Greg left me wondering if and how other therapists were considering their own experiences.

Each client will bring forth something unique and of relevance for them in the arena of politics, or may not mention it at all. Some discuss keeping purposeful distance from the news, turning off alerts the phone and decidedly not reading the paper. More than a few clients asked directly if it was appropriate to use their psychotherapy time to talk about what was going on. Some were frank in their need to know, or at least inquire, about my ideological leanings to feel comfortable enough to proceed. One young woman expressed anxiety that she might offend me with her opinions. My curiosity about the impact of my responses and how other therapists may have reacted, responded and managed similar situations was the impetus for this exploration.

Research Question and Design Given the intensity of the collective external socio-political environment in the U.S. of late and the possibility of new uncharted clinical experiences related to this phenomenon, this qualitative study focused on the subjective experience of the therapist when politics presents in the therapeutic hour, and how it is managed, and responded to by the therapist. Using a Grounded Theory approach, (Corbin & Strauss, 2008; Mishler, 1986) data was collected by conducting in-depth semi-structured, open ended interviews with five seasoned psychotherapists who work in a private practice setting. The research question asked how therapists responded to, worked with, and conceptualized political material that emerges in psychotherapy sessions. Therapists were asked to elaborate on

13 their personal and professional experiences with what they determined to be political material, including detailed clinical vignettes. Some of the sub-questions that the project attempted to understand included: 1. What is considered political material by therapists? When political material does emerge in practice, how do therapists conceptualize and respond to it (explicitly and implicitly) and how to they think about it outside of the therapy? What is the impact therapist and client responses on the treatment relationship and on the therapist personally?

2. How do therapists acknowledge the experience and impact of sharing an external political reality with clients? How do therapists understand their role in relation and response to a shared external political reality? How do they manage self-disclosure? Has this changed over time?

(See appendix I) The “constant comparative method� of qualitative data analysis as described by Corbin and Strauss (2008) was used to analyze data from the study. The diversity of the subjects and their experience was considered as part of the analysis of the data obtained.

Theoretical Framework The intention of this study was to ground the analysis of the data collected within the context of a relational/intersubjective (Greenberg & Mitchell, 1983; Mitchell, 1988, 1993; Stolorow & Atwood, 1993, 1996) and affect regulation/neurobiological theoretical framework (Schore 2003a, 2003b; Hill, 2015). These theories work from the premise that individuals are shaped in part by the context in which they exist, and are constantly affected by relationships and experiences (DeYoung, 2015). Influenced by infant

14 research, (Lachmann & Beebee, 1988, 2003; Stern, 1985), feminist psychoanalytic theory (Benjamin, 1988, 1995; Chodorow, 1989, 2002), and cross cultural psychoanalytic literature (Altman, 2010; Maroda, 1999), relational/intersubjective theories offer a strong lens to consider political material and issues in a psychotherapy relationship because of the emphasis on the relational matrix, impact of external factors and acknowledgement of the subjectivities of both client and therapist as influences in therapy (Wachtel, 2017). In relational/intersubjective theory the apolitical, neutral stance is challenged and gives way to a co-created therapeutic experience that includes the therapist as a participant. This perspective offered a base to explore the impact and outcomes of “the political� on the therapeutic experience.

Additionally, theories of neurobiology and affect regulation (Bromberg 2011; Schore 2003a, 2003b; Hill, 2015) are an avenue to more deeply understand the processes that may occur between client and therapist. These theories are not mutually exclusive to a relational/intersubjective theoretical perspective and may supplement the psychoanalytic theory and practice, and help to explain categories generated by the qualitative data. Regulation theories, that describe how affect is represented in the body, add depth to our potential to understand political material in psychotherapy sessions, particularly considering the intrusive nature of news and social media. If regulated affect is a key to functioning well and if reports of dysregulated affect increase after politically charged moments in time, then the connection between how we metabolize sociopolitical material and its impact on affect regulation is relevant to this exploration.

15 Definition of Concepts “Psychotherapist/Therapist” and “Psychotherapy.”

For the purposes of this research, the terms “psychotherapist” or “therapist” was referred to interchangeably and includes a licensed clinician (MSW, MA, PhD or PsyD) who provides psychotherapy. The literature reviewed may also use the term, “analyst” or “psychoanalyst” to refer to the practitioner as well.

The terms “psychodynamic psychotherapy,” “psychotherapy” and “therapy” was used interchangeably and referred to the direct practice between therapist and client, typically occurring once or twice a week in face to face sessions. The literature reviewed also used the term “analysis,” or “psychoanalysis” to refer to the direct practice work.

This research aimed to understand the interactions between psychotherapists and their clients engaged in a process of psychodynamic psychotherapy together. The spirit of psychodynamic psychotherapy is described by Shedler (2010) as, “exploring those aspects of self that are not fully known, especially as they are manifested and potentially influenced in the therapy relationship” (p. 98). Later in the same article, Shedler identifies features of process and technique in psychodynamic psychotherapy as: 1. Focus on affect and expression of emotion 2. Exploration of attempts to avoid distressing thoughts and ideas 3. Identification of recurring themes and patterns 4. Discussion of past experience (developmental focus) 5. Focus on interpersonal relations 6. Focus on the therapy relationship 7. Exploration of fantasy life (p. 99).

16 Therapist-participants engaged in a psychotherapy process that included Shedler’s features noted above.

“Politics.”

Politics means many things to different people. The term “politics” is most often defined as having to do with government. Merriam-Webster (2017) dictionary defines politics as the art or science of government and includes concerns surrounding the influence of policy, aspects of winning, and controlling government. Politics can also refer to the opinions or ideology of individuals and the relations between those living in a society. The word political is derived from the Greek term politikos which translates to, “of or pertaining to, the polis.’” Polis, the ancient city-state, is reflective of a group of citizens with a sense of community (Miller, 1998). Greek philosopher Aristotle, instrumental in the development of political theory, stated, “Every state is a community of some kind, and every community is established with a view to some good; for mankind always act in order to obtain that which they think is good” (Aristotle, 384-322 BCE, in Somerville and Santori, Eds, 1963, p. 60). Aristotle’s work contributed to thinking about the role of human nature in politics, the relationship of the individual to the state, and the importance of educated citizens (Miller, 1998). Aristotle acknowledged, “Now, that man is more of a political animal than bees or any other gregarious animals is evident” (Aristotle, 384-322 BCE in Somerville and Santori, Eds., 1963, p. 61). Aristotle expected individuals to participate and acknowledge they are innately political. His legacy includes thought about the importance of the individuals’ responsibility to the state and government.

17 Modern definitions of politics have expanded to include the process of making decisions for a group or the use of authority or power. “…There is the politics of the American electoral process; the politics of race, gender, and class; the politics within the field of psychotherapy, the community, the family, the office, the romantic couple and so on. In general politics refers to the exercise of power” (Cushman, 1995, p.332). Most commonly, politics is associated with the exercise of power and the way power is used by interests (state, institutions, groups) to transform, maintain and gain control over behavior, survival, or economic outcome (Avissar, 2016; Cushman, 1995; Samuels, 1993) Avissar (2016) also highlights that the role of power relations and the way actions affect others may be explicit or implicit. For Samuels (1993) in addition to, “the organization and distribution of resources and power,” there is a more personal politics that refers to the struggle over a sense of agency and action.

For the purposes of this research, “politics” is defined as issues related to electoral government, legislation and policy as well as and including matters of relations between others; power, authority, and influence within and among individuals and between groups of people. Matters of economics, social issues, human rights, environment, race, class, gender, and domestic and global policy are political. The individual’s relationship to power both intrapsychically and interpersonally, is political.

“The political in psychotherapy.”

Psychotherapy and the political are linked in a reciprocal relationship (Samuels, 2006). This research used the data from subject interviews to determine what is considered political in psychotherapy. “Politics, political material or content, political

18 issues in psychotherapy” whether explicit or implicit in psychotherapy sessions, was determined by the interviewee and was subjective to that therapist’s definition of the meaning and content of political.

“Reality” and “shared reality.”

Finally, it is useful to note that the term “reality,” used in the context of the “shared reality” or “shared external reality” reflects common real-world events and circumstances in the social and political domain, captured in the news and exposed to by both therapist and clients outside of psychotherapy sessions. “Reality” does not imply that exposure to real-life circumstances (like those in the mainstream news) will be perceived or reacted to as truths by everyone. There was no assumption that current events hold the same meanings, symbolism, internalizations and significance, responses or reactions for any two individuals. The lens through which individuals consumed the external reality differed. Bromberg (2011) supports the idea that objective reality is valid, but perspective and reality is shaped by the “self-state.” It is necessary to clearly identify that the use of “reality” in this research does conflict with concepts of intersubjectivity.

Significance of the Project Discussion of “the political and psychotherapy” in the literature is fixed by the historical context of its time (Totton, 2008; Layton, Hollander & Gutwill, 2006; Ruderman & Tosone, 2013; Samuels, 1993, 2001, 2004, 2006, 2015, 2017a, 2017b; Avissar; 2016). This dissertation is also tied to the time in which it occurred and addresses a constantly changing, ever evolving political atmosphere. In the fall of 2017, I

19 attended a lecture in which Andrew Samuels, author, activist, psychoanalyst, and professor in politics and psychotherapy, spoke to a group of therapists and analysts in Los Angeles (Lecture at C.G. Jung Institute of Los Angeles, October 13, 2017). The topic was political violence and when he asked the group to consider their own fantasy of participation in political violence, the responses overwhelmingly focused on negative and vitriolic reactions to the current U.S. President. I wondered then, how has the therapist’s state of mind around this topic impacted how they respond to and conceptualized political discussion and material in sessions? While Samuels deftly managed the discussion, and moved the conversation towards the topic at hand, I was left feeling assured about the significance of exploring in depth how therapists respond to, work with, and conceptualize political material that emerges in psychotherapy sessions as a body of research that will contribute to the profession.

Samuels (2017) refers to a “political turn” in psychotherapy, by which he may mean a movement towards a focus on “political and psychotherapy.” He acknowledged that the profession was getting better at integrating political and collective perspectives into responsible relational clinical work (Pacifica Graduate Institutes, YouTube, September 6, 2017, https://www.youtube.com/watch? v=WI0c7hyy6pg&feature=youtu.be). This research expanded upon this effort by capturing a slice of what is happening behind closed doors of the therapy room and in the therapist’s mind. In the forward to the 2017 book, The Political Self: Understanding the Social Context for Mental Illness by Ron Tweedy, Samuels argues there are seven areas of politics and psychotherapy to consider. This project considered areas six and seven:

20 VI. The struggle to apperceive the micro-politics of the therapy session itself – the power, vulnerability, and differing experiences in the therapy and in the social world of both participants….VII. Devising responsible ways to engage directly with political, cultural, and social material that appears in clinical session.

(Samuels, 2017, p .xxi).

The interviews highlighted themes and categories that help explain how differing experiences with politics play out for both the therapist and client and document the ways in which the therapeutic dyad is engaged together to work with political material directly in the context of the special circumstance of therapy. “What we need to do is highlight the therapeutic value of political discussion under taken in a responsible and relational way that acknowledges the dangers. It is not going to be the same as discussion held in a bar or over dinner or at work” (Samuels, 2017, p. xxii). This research addresses some of the ways that therapists engage with and think about politics, something Samuels suggests is necessary for good clinical practice (http://www.pacificapost.com/topic/therapist). However, Samuels (2004) advocates that good clinical political practice ought to include, “all aspects of work on the political dimensions of experience” and not only focus on interactions during intensified political times of shared trauma or disruptive experiences that are out of the ordinary (Samuels, 2004, p. 828). While I agree, this makes for good practice, this study could only consider how therapists reflected upon their work and experiences leading up to and including the time of the interview, a time in which heightened external socio-political situations were constant and intense. While the circumstances in which this dissertation was completed are not in accord with Samuels’ hopes for the standard in addressing politics in

21 psychotherapy, it offers insight into the ways in which an extraordinary situation may have created growth and development that could persist beyond a situational circumstance.

This dissertation included the implications of the political environment the subjects have experienced and captured how participants understand the impact of current events on practice. One article (2017) titled, “Why Therapists Are Having Such a Hard Time Talking About Trump”, highlights a therapist who explains that although she was trained not to share her political views, she now finds herself agreeing with some clients around their political views in session, a challenge to the way she typically practices (Karlamangla, Los Angeles Times, February 24, 2017). In the same article, another therapist, Randi Gottlieb, is quoted, “It’s putting into flux and questioning how do we practice, what is the best way to support the people we care for. We’re beginning those conversations — we don’t really have good answers” (Karlamangla, Los Angeles Times, February 24, 2017). The exploratory qualitative nature of this project offered more depth and discussion than the antidotal essays, opinion pieces, and periodicals being published since the election.

This work is intended to further the discussion around how therapists understand the political in session and how they respond, something recent current events have challenged therapists to consider. In his piece, Eyal Rozmarin (2017a) notes that even though these issues are not new, “…what has been going on and how it affects us is primary, not representative. These days this is our subject matter (if it ever isn’t)” (p.

120). He goes on to muse and consider questions like what is the “analytic stance” in this situation? And he acknowledges that, “times such as this collapse the regular, the well-

22 regulated” (Rozmarin, 2017a, p. 121). This statement is especially poignant as it speaks to the potential impact on affect regulation for clients and psychotherapists and it reinforces the importance of using a theoretical framework that includes the intersubjective, relational and interpersonal neurobiological thinking to better understand these phenomena.

Research and literature on the concepts of “shared traumatic reality” or “shared reality” describes the collective experiences and exposure to trauma by both parties in the therapeutic dyad (Baum, 2010, 2012, 2014; Baum & Dekel, 2010; Bauwens, Glassman, & Tosone, 2014; Benyakar, Baruch, Kretsch & Roth, 1997; Keinan-Kon, 1998; Tosone, 2011; Tosone, Nuttman-Shwartz, & Stephens, 2012). While the bulk of this literature addresses man-made and natural disasters, they do not discuss the effect of a shared political reality or a heightened socio-political collective trauma. This research considered the usefulness and relatability of this literature to recent experiences in therapy.

A timely and sensitive interview process and structured methodology allowed the researchers to better understand the content of political material, its impact and effect.

Seven months after the election a client was discussing in session with me an issue related to asserting herself with others. She said, “I mean, in these times we all have to practice making our voices heard. It is no longer ok to be silent and I have to practice this personally so I can do it on a larger scale. I don’t have the luxury of staying silent. None of us really do.” (private communication, 2017). My choice to pursue this topic for my dissertation was, in part, working towards making my voice heard. It hope that my subjects found participation the study an opportunity to participate in the growth and

23 development of the profession. The significance of this project is personal to me. It has served as a way to comprehend my own clinical experiences of late in a larger context and has offered me an avenue to participate in the profession in a larger sense, and function as a personal political action.

24

Chapter II Literature Review Introduction This exploratory research asked how therapists respond to, work with, and conceptualize political material that emerges in psychotherapy sessions. A review of the literature relevant to this project included material covering a vast variety of categories.

There is not one single body of literature and research that addresses the topic of politics and psychotherapy. Many of the results in a search for “politics and psychotherapy� yielded writing focused primarily on the politics of psychotherapy, either discussing the ways that power is manifested between therapists and clients, among the profession itself, and/or between the profession and the world at large. Such literature extended beyond the scope of this project, as here, the intention was to focus on the subjective experience of the therapist by questioning if and when politics presents in the psychotherapy hour, how so, and how it is conceptualized with consideration of the possible influence of a shared external socio-political environment.

The literature reviewed below was organized to move from a broad overview of general areas into a more detailed review of specific concepts and theories. A brief note about Freud’s apolitical intentions set the stage for the birth of psychoanalytic thought and psychotherapy. However, the discussion fast forwards quickly, moving to literature that is based in a two-person psychology and considers both the intra and inter personal

25 aspects of the individual in treatment. Relational/Intersubjective theory was reviewed in terms of how the apolitical, neutral stance is challenged and gives way to a co-created therapeutic experience that includes the therapist as a participant. Concepts of recognition and intersubjectivity were highlighted. Contributions from neurobiological, affect regulation and polyvagal theories offer an avenue to more deeply understand the processes that occur between client and therapist, and attend to dysregulation noted as a result of political issues.

Literature that addresses how, when, why therapists encounter and interact with political issues in psychotherapy was highlighted. Also, an effort was made to understand how these authors conceptualized their experiences and consider if the political is located outside the client or therapy vs. inside or intrapersonal for the client. This led to a deeper review of therapist self-disclosure. Of interest, the literature on non-immediate or interpersonal disclosures shares possible risks and outcomes with the literature on shared traumatic reality. Thus, a review of clinical work and literature about the concept of shared reality or shared trauma was reviewed next. This literature speaks primarily to man-made and natural disasters and it leaves one wondering if current social and political events might qualify as a shared traumatic reality. Next, a review of the constructs of national and collective trauma were included, as they help define current political events in the United States. This literature considers that no matter the ideology of an individual, if groups of people are responding collectively to an ongoing disruption, then we are operating within the context of a national trauma. Revent previous research was noted.

Just as the current events unfolding in the external reality continually changed and evolved during the course of the research process, the literature on this topic was

26 evolving as the research was conducted. Most recent relevant contributions to the discussion of politics and psychotherapy in the professional literature that were published in 2017, 2018, and 2019 were primarily included in the discussion chapter of this research due to the timing of research and writing of the project.

The Beginnings: Freud, Power, and Politics Freud is an appropriate place to begin a review of literature pertaining to politics. It is impossible to discuss his work and theories without acknowledging the historical, social, and political context in which they emerged. Brunner (2001) argues that there are multiple factors in Freud’s work that relate to the political. He asserts that political reasoning is a part of Freud’s theoretical structures; that concepts of id, ego and superego, symbolize a struggle over resources of the mind and mirror economic struggles like those at the core of politics. Brunner (2001) further describes how Freud’s work cannot be separated from the issues of race, class and gender of the time and thus, the politics.

“Freud regarded the experience of power and powerlessness, which lies at the core of the political, as primary to humans” (Brunner, 2001, p. ix). However, Brunner (2001) is also very clear that even though he has found a relationship to politics and political theory in Freud’s texts, words and logic, he does not believe Freud would acknowledge this or agree. He maintains that Freud’s intention or motivation was specifically not intended to be political or contribute to political theory. “In my view, Freud was insufficiently aware of the fact that his attempt at an integration of casual explanations and interpretations of meaning turned his project into a political science of the mind, individual action and social institutions and processes” (Brunner, 2001, p. 183). Brunner (2001) argues that

27 Freud began to address issues of power and conflict and Brunner encourages the profession to, attempt to develop a discourse on power which is applicable not only to the external world but also to the mind’s internal reality, intertwines the interpretation of meaning which casual explanation, and thereby continues a project which Freud initiated about a century ago. (p. 186) Freud himself attempted to avoid contributing to political theory because of his desire and instance that his theories be accepted on a scientific level. “…he feared that open political activity on the part of analysts could only interfere with his project of establishing psychoanalysis as a credible scientific discipline” (Botticelli, 2004, p. 636).

However, Freud’s call for the operation of free clinics was seen as a political act, revealing a desire to offer treatment for those underserved; an intent to provide psychoanalysis for the masses (Avissar, 2016; Brunner, 2001; Gay, 1989; Totton, 2000).

Europe in the time of Freud, “already encompassed a strong social conscience.

Psychoanalysts were vocal in their beliefs as well as in their sense of responsibility to provide services to all economic classes through free mental health centers.” (BenitezBloch, 2012, p. 33). However, a review of Freud’s political views is separate from the consideration of the clinical work he inspired. His intention that psychoanalysis be carried out by the analyst with a sense of authority and neutrality raises questions about the political nature of the psychoanalysis that developed as a result, and warrants review of how or if acknowledgment of external reality developed in the clinical hour. Further review of Freud’s concept of neutrality and stance on disclosure is noted in the literature review section on self-disclosure.

28 Here we fast forward in the literature, about 50 years, during which the psychoanalytic movement came to the U.S. and theories transformed and changed over time. Multiple schools of thought emerged and an evolution from Freud’s one-person psychology, to a two-person psychological system became focus of the preeminent theories.

Theory There must be a theoretical lens through which to understand and make sense of the clinical data that therapists shared about their experiences with political material and themes in therapy. A literature review and description of relational/intersubjective theories is essential to highlight the intersubjective nature of the co-created space between therapy participants, coupled with concepts that focus on contextualized relational experiences as impactful. Additionally, neurobiological concepts that discuss affect regulation theory deepen the discussion of the narratives collected. Relational theory helped define how to look at the data. The concept of the therapist’s subjectivity, issues of self-disclosure and boundaries, as well as concepts of “inside” and “outside” are relevant to this study. Subjects were asked about their clinical experiences, what, if anything they choose to disclose around politics and how they conceptualized these choices. As Hoffman (1983) notes, “existing theoretical models inevitably influence and reflect practice” (p. 389). Thus, understanding how relational/intersubjective and neurobiological/affect regulation theories and concepts are defined by the literature provided insight into how concepts were integrated and echoed in real therapeutic relationships. Below, I will review relational theory, its development and major

29 contributors, the practice of a relationally based psychotherapy, and the concepts of recognition and intersubjectivity to pave the way for a discussion of self-disclosure.

Relational Theory The relational perspective represents the evolution away from classical oneperson, drive-based theories towards the inclusion of two-person, inter-psychic models which consider nature and nurture as major influences in development (Mitchell & Black, 1995; Perlman & Frankel, 2009). Aron (1996a) notes that, “the relational paradigm may be seen as a new integration of psychoanalytic concepts and approaches that offers a formidable alternative to classical psychoanalytic theorizing� (p. 3). Relational theory works on a premise that individuals are formed in relation to their social contexts and these relationships and experiences; real, imagined, internal or external, are all central to the development of the self. (DeYoung, 2015, Aron, 1996a). Mitchell & Black (1995) explain that where drive theorists might see an intrapsychic arrested development best attended to by an attempt to lift represson, a relational therapist might try to inquire about the impact of earlier relational experiences, and may attend to the insights gained with greater consideration to the interaction and subjectivities of therapeutic dyad (Mitchell & Black, 1995; Mitchell & Harris, 2004). Intrapsychic and interpersonal influcences are seen as complementary. Mitchell (1993) summarizes, On the one hand, isolating any aspect of human experience or the analytic relationship outside of its embeddedness in an interactive, relational matrix starts one off on the wrong footing. On the other hand, to consider only that which is currently interactional for fear of intra-psychic ghosts is a massive and

30 unfortunate overcorrection. The human psyche, in my view is both intrapsychic and interpersonal, simultaneously both a one-person and two-person phenomenon (See Benjamin 1992b, for a similar view). (p. 143) Relational theory does not reflect a singular school of thought (Aron, 1996a, 1996b; Bromberg, 2009; DeYoung, 2015; Perlman & Frankel, 2009). Berman (1997) expressed hope that Relational psychoanalysis will, “help in molding a professional and intellectual climate free of the constraining impact of “schools” (p. 185). Contemporary contributors to Relational literature draws from an array of theories including, the interpersonal school, object-relations, and self-psychology (Aron 1996a, 1996b, 2005; Bromberg 2009; Perlman & Frankel, 2009). Contributors to the discipline’s theoretical lineage, including Ferenzci, Kohut, Sullivian, and Horney, among others, “are all important parental figures but none carries parental authority” (Bromberg, 2009, p. 348).

The term ‘relational’ was agreed upon by a group of analysts, led by Stephen Mitchell, to represent the common view that; “That the human mind, its normal development, its pathology, and the process of its therapeutic growth are relationally configured....”

(Bromberg, 2009, p. 348). Mitchell (Greenberg & Mitchell, 1983; Mitchell, 1988, 1993; Mitchell & Black, 1995; Mitchell & Harris, 2004) is considered to have been instrumental in the movement of Relational theory in contemporary literature, including the establishment of, Psychoanalytic Dialogues: A Journal of Relational Perspectives in 1991. However, “today it seems that the term intersubjectivity, like the term relational, is generally used boradly to convey a wide range of revisionist, generally post-Freudian theories” (Aron, 1996b, para.10).

31 Contributions to relational theory.

Infant research.

Infant research confirms the mutual influence between infant and caretaker and the development of a sense of self within a relational field. The work of Beebee and Lachmann (1988, 2003), Stern (1985) and others, supports the concept that relational processes exist at birth; that infants have an inner state and experience relations between self and other immediately (Lachmann, 2004). The significance of these findings furthered the development of relational theories that rest upon the idea that a core sense of self is being developed from birth in relation to our environment and caregivers.

This body of work documents the degree of continuous mutual influence and regulation occurring between people outside of their awareness, and thus provides an empirical and conceptual foundation for the close attention paid by relational analysts to the interaction between client and therapist and to the enactments that are co-constructed by both (Hoffman, 1998) (Perlman & Frankel, 2009, p. 119).

Feminism, feminist theory and politics.

Feminism and feminist voices moved psychotherapy and analytic theory towards the political by infusing theory with a “voice,” a perspective, and what might be considered as a polticially minded attitude. Including a feminine perspective in theory coincided with and was propelled by feminist movements in the 1960s and 70s. The origins of the term, “the personal is political” is often linked to a paper with the same title, published by Carol Hanish in 1970, although Hanish denies that she coined the term (Hanisch, 2009). The author clarifies that her definition of political here has to do more

32 with power relationships and is not narrowly defined as electoral politics (Hanisch, 2009). The term, “the personal is political” is meant to qualify that women’s personal experiences are rooted in a system of power relationships that contribute to those experiences. In her original paper, Hanish declared the need to acknowledge the difference between “therapy” or “personal” which she disavows as suggesting that she (the woman) change vs. “therapy and politics” or “the political” which removes selfblame and acknowledges the external oppression of women (Hanisch, 2009). Hill and Ballou (1998) note that shifts in feminist theory led to a perspective captured by the term, “the political is personal” to acknowledge sociocultural and structural influences on the psychological. Feminist theory and therapy differ from psychoanalytic theory in that it has a political intention to create social change. Feminist therapists are, “practicing a therapy that creates both an awareness of sociocultural inequities and an alternative experience for the client” (Hill & Ballou, 1998, p. 2).

Feminist voices in the work of Benjamin, Harris, Chodorow, and others offered attempts to address sexist bias in analytic theory and in doing so have furthered theoretical understandings of human development. “Relational theory has likewise proved to be a site for integrations with feminism and queer theory” (Harris & Suchet, 2002, p. 104). Feminist therapy is a political action in that it has a perspective and takes a stand that skews from neutral (Avissar, 2016, p. 47). Feminist theory developed in reaction to existing male biases in psychoanalytic theories including an inflexible separation between subject and object. Feminist theory also crosses psychoanalytic theory in the work on recognition, as it moved the traditional ideas of mother figures from an object to having her own subjectivity. Benjamin’s work (1988, 1995) expands the

33 connection between the mother-infant dyad from a subject/object relationship to one that recognizes the mother’s subjectivity. This goes hand and hand with the infant research and neurobiological advances that confirm the mutual reciprocal nature of relationships.

Benjamin (1988) points out that intersubjectivity or the recognition of the other as more than an object, is a developmental goal, and a intended experience in the therapeutic relationship (Berman, 1997). Benjamin (1988) culminates her work The Bonds of Love by stating that an attempt at recognition enables awareness that, “…the personal and social are interconnected, and to understand that if we suffocate our personal longings for recognition we will suffocate our home for social transformation as well” (p. 224).

Relational theory and social work.

Relational theory has been tied to social work practice (Tosone, 2004; Seibold, 2011; Ornstein & Granzer, 1997, 2005; Wineburgh, 2013; Segal, 2013; Schamess, 2012).

Sanville (1997) discusses the natural tendency of social work to consider that individuals are influenced by their setting and social context. She suggests that social work has leaned toward a constructivist viewpoint, meaning context and personal vantage point influences meaning. “Truth, as such, does not exist, that experience is subjective, and that in interactions it is intersubjectively organized” (Sanville, 1997, p. 22). Berger (2013) highlights social work’s perspective of considering the person-in-environment and the individual’s bio-psycho-social experience. The roots of social work use psychoanalytic theoretical ideas on top of an understanding of the individual as part of a family, community and system (Berger, 2013).

34 Relational psychotherapy.

Relational psychotherapy is a broad integration of an array of theories, theorists, and research; a method of describing how and why we exist in a particular way when we are in relation with others and with ourselves, as well as more deeply understanding how those patterns developed in our early lives. Using a relational perspective to look at clinical work calls into the forefront how each therapist must attune and shift differently for each client, both because of what the client brings and because of who we are individually as therapists. Thus, it enables us to ask how each therapist/client dyad respond, attune and shift to implicit and explicit political material.

Relationally based psychotherapy is grounded by the opportunity for the clinical dyad to exist and participate in space that holds their subjectivities, objectivities and a cocreated space that is unique to only that relational interaction. However, the inquiry that occurs during therapy is not free from assigned value by its participants. Reality is not fixed or singular but dependent upon context and experience (Palambo, Bendicsen, & Koch, 2010).

The concepts of empathy, relational attunement, authenticity, and mutuality are used in treatment as ways to allow clients to feel deeply understood based on the premise that feeling, being seen, understood and responded to with attunement can lead to psychic change. Further, relational work includes the idea that ruptures, missteps and misattunements are a part of every relationship. There is some assumption that clients will relate with the therapist in similar ways that they do with others and expect similar responses. When therapists offer empathy, attunement, regulation of affect and new responses, opportunities for clients to experience something new and different arise. In

35 the same vein, because the therapeutic relationship is a real one, there are bound to be moments when clients feel misunderstood, unseen, or feel angry, hurt, anxious, or activated by something that occurs in the therapeutic space. These moments are important opportunities in therapy. Relational work considers that what is offered by the therapist is also inevitably tied to the therapist’s own subjective internal experiences and ability to be with clients in these moments. Recently, Wachtel (2017) suggests furthering Mitchell’s contributions to by acknowledging: It is a central premise of relational thought that behavior and experience must be understood in the context of the relational matrix in which they are manifested.

But it is relatively unusual in the relational literature to see detailed discussion of the ways in which everyday life experiences shape the internal object world; much more often the opposite direction of causality is the focus (Wachtel, 2017, p. 518).

Wachtel’s (2017) acknowledgement clarifies that there is room to further explore the way that politics manifests in psychotherapy sessions, either as a metaphor or more literally. This influenced consideration of the subjects’ perspective of how life experiences, and the shared experiences of political reality, shape the internal world.

Botticelli (2004) also concludes, “The shift in focus in psychoanalysis from intrapsychic to intersubjective, from examination of the vicissitudes of drive to attention to the relational world, seems to provide more space for social and political dimensions to enter consideration” (p. 637).

36 Concepts in Relational Theory The emphasis of relational theory is on the, “contextual, relational nature of the psychanalytic clincal process and the concepts it generates” (Mitchell & Harris, 2004, p.169). The concepts most relvant to this study include intersubjectivity, recognition, the analyst’s participation and self-disclosure. The related work of Intersubjective Systems theorists (Stolorow & Atwood, 1992, 1993, 1996) also adds to models of relationallybased clinical theory and this additional perspective deepens the understandings of relationally based concepts (Ringstrom, 2010). Other psychological, psychoanalytic, and neurobiological theories of mentalization, attachment, dynamic systems theory, affect regulation and interpersonal neurobiology contribute and help elucidate the co-created process of regulation, mutual recognition and intersubjectivity that occurs both explicitly and implicitly within the psychotherapy process (Bromberg, 2011; DeYoung, 2015; Hill, 2015; Schore, 2011, 2012). Below I will highlight some of the major contributions to relational theory and outline some of the concepts that were useful for understanding the data collected in this study.

Recognition.

Jessica Benjamin uses intersubjectivity to hone her theories of recognition and mutual recognition. “Whereas the intrapsychic perspective concieves of the person as a discrete unit with a complex internal structure, intersubjective theory describes capacities that emerge in the interaction between self and others” (Benjamin, 1988, p. 20). Mutual recognition acknowledges the need that one has to be recognized and the need to recognize the other as a separate being as well. In a 2006 roundtable discussion about

37 politics Benjamin said, “I think that, first of all, there’s a kind of fury around nonrecognition that people can feel in relation to politics. And politics is where we project certain dissociated identifications with, say victimhood that are very powerful, that we tend not to examine” (Layton, Hollander & Gutwill, 2006, p. 181).

Muriel Dimen (2006) argues that if relational theory uses the concepts of multiple self-states and of “multiplicity in intersubjective and interpersonal experience,” then maybe we can include a civic-self as an aspect of one’s experience (p. 199). She is proposing that part of what might occur in therapy is the actualization and recognition of a civic aspect of internal experience in the client. Dimen (2006) asserts, “We are always political beings, as much as we are all creatures of need, desire and unconsciousness” (p.

199).

Intersubjectivity and therapist subjectivity.

Intersubjectivity for Stolorow, et al., refers to a relational field in which there exists contant and continual mutual influence and mutual regulation shaping experience (Stolorow & Atwood, 1996, Aron, 1996a). “Intersubjectivity theory is a field theory or systems theory in that it seeks to comprehend psychological phenomena not as products of isolated intrapsychic mechanisms, but as forming at the interface of reciprocally interacting subjectivities” (Atwood & Stolorow, 1993, p. 178). These theories are interested in the analyts’s countertransference and subjectivity, the patient’s transference, and a recognition of the deeply personal and interpersonal nature of the the analyst’s participation (Mitchell and Harris, 2004, p. 169). This intersubjective view, as distinguished from the intrapsychic, refers to what happens in the field of self and other

38 and refers to capacities that emerge in the interaction between self and others (Benjamin, 1988). It is the essential need, ability and/or desire for recognition that seems to permeate all theories of intersubjectivity. “Change and psychological growth, it is now increasingly clear, derive not just from understanding oneself but from being understood by another person” (Wachtel, 2011, p. 108).

Altman (2010) writes, “Anonymity and nongratification are no longer psychoanalytic imperatives; in fact, such a stance tend to be seen as impossible to achieve” (p.61). According to Altman (2010), the analyst’s subjectivity is being revealed in any therapeutic interaction. The client’s transference is viewed not only as reflecting biases, preconceptions, and organizing principles that the patent brings to the interaction, but also as a reflection of the client’s possible or plausible perceptions of the analyst.

“The analytic goal then is to impart insight and to facilitate a collaborative inquiry into the nature of the analytic interaction, to develop awareness of the patient’s active role in creating interpersonal patterns, without denying the analyst’s contribution, and to foster flexibility where there was rigidity” (Altman, 2010, p. 61).

It is noteworthy to add here that Andrew Samuels (2014, 2015) expresses some concern and possible limitations to relational practice, particularly when considering politics and political material.

Relational intersubjectivity may undermine or exclude individual subjectivity. “the therapeutic relationship” that is supposed to take the strain, not the sweating individuals who compose it. It’s all about dyads, dialogue, communication, attachment, attunement, rupture and repair, transference-countertransference. This

39 refusal of one-person psychology has gone too far. The therapeutic relationship has become an oppressive, conventional, moralistic norm (Samuels, 2015, p. 74).

As an activist and advocate, Samuel’s intention is for all psychotherapy to include the development of the political self in the individual (1993, 2001, 2004, 2015).

These theoretical insights bring the literature around boundaries, therapeutic “frame,” and self-disclsoure into focus next as a means to better understand how, why and what happens when the therapist’s subjectivity and is revealed either inevitably or as a choice.

Self-Disclosure Therapist’s self-disclosures are defined as verbal statements that reveal personal information about the therapist to the client (Farber, 2006; Knox & Hill, 2003). Given that a person’s experience is embedded in context and no therapist is offering services in a vacuum disassociated from the socio-political events that surround them, it is important to consider the ways in which such events might impact a therapist’s practice and disclosures in the treatment room. Literature and research on therapist self-disclosure is primarily centered around the frequency, nature, type, reason, purpose, and effect of purposeful verbal disclosures in therapy (Audet, 2011; Audet & Everall, 2010; Henretty & Levitt, 2010; Hill & Knox, 2001a, 2001b, 2003). Some disclosures are considered inevitable; office décor, therapist dress, ethnicity, political or public activities outside of the therapy can disclose aspects of the therapist to the client by observation. A client may see you get out of your car, in the supermarket or even note a new pair of shoes.

Technology and the Internet allow many characteristics of a therapist’s life to be readily

40 available in the public domain. Psychodynamic and analytic literature considers the implication of implicit, nonverbal and purposeful verbal disclosures as part of any modern relationally based therapy (Aron, 1991, 2005; Bromberg, 1994; Greenberg, 2001; Maroda, 1999). Greenberg (2001) notes, “Everything the analyst says (and a great deal of what is not said) will affect the patient deeply” (para. 9). Therapist self-disclosure is integral to better understanding how therapists respond to and conceptualize political issues in psychotherapy. Interviews revealed reflections about decisions related to therapist self-disclosure. Subjects were asked directly how they managed self-disclosure in the context of “the political” and within the context of a “shared reality” of current environmental events. A brief review of the history and nature of therapist self-disclosure helps to define and understand it as a concept. Types of self-disclosure and their resulting impacts are reviewed. The relational/intersubjective theories that this research is grounded in considers the therapists’ subjectivity as an integral part of treatment and selfdisclosure as inevitable (Aron, 1991; Maroda, 1999). “The essential contribution from contemporary relational theory is the inclusion and explicit valuing of the therapist’s participation” (Ornstein & Ganzer, 2005, p. 567). How the realm of “the political” and external current events intersect with implicit and explicit therapist disclosures, was considered as part of the discussion of the findings of this research.

Why we disclose.

Barry Farber (2006) consolidated research and literature on self-disclosure and reflects that in general, revealing personal information between people “undoes” silence, distance or ignorance” (Farber, 2006, p. 4). He also notes six positive features or effects

41 of disclosure in general; intimacy, validation, insight, differentiation of self, authenticity, and relief.

In short, we disclose in order to feel closer to another, to feel validated by another, to understand and strengthen the core aspects of our identity, to explore and accept multiple aspects of ourselves, to feel more genuine in the world and to relieve the burden of unexpressed pain (Farber, 2006, p. 13).

Farber (2006) asserts that negative results of disclosure include a possibility of being rejected, burdening another, creating undesired impressions of ourselves, and increasing vulnerability, regret, or increased shame, especially about disclosure of material that is discrepant with our ideal of ourselves.

Of significance to this project, Farber (2006) comments on the impact of the external culture’s seeming increase in desire for greater intimacy; noting the rise in desire to share intimate things via reality television, blogs, social media, and a cultural “tell-all mentality.” He also acknowledges that there is likely a rise in the need to share after extreme events, citing September 11th hurricanes, natural and man-made disasters as examples (Farber, 2006, pp. 7-8). Given the context of the political events in the US, this research occurred during a time in which there may have been and continues to be a greater desire to disclose and share. While Farber’s (2006) work touches on special therapist-client circumstances and self-disclosure (pregnancy, disability, sexual orientation, serious illness) he does not discuss the impact of politics or an external political reality on self-disclosure specifically. There is not a preponderance of literature that specifically discusses the combination of therapist self-disclosure and politics and psychotherapists engagement with political material in general (Milton & Legg, 2000).

42 Notable, exceptions include discussions of Israeli conflicts (Ringel, 2002; Avissar, 2007, 2009), the literature on shared trauma (see literature in shared trauma section of this literature review) and some emerging literature about psychotherapy after the election of Donald Trump. There is one published roundtable dialogue between Neil Altman, Jessica Benjamin, Ted Jacobs, Paul Wachtel moderated by Amanda Hirsch Geffner in a volume edited by Layton, Hollander, & Gutwill (2006) that specifically addresses the intersection of politics and psychotherapy including questions about self-disclosure.

History of therapist-self disclosure and neutrality.

Therapist self-disclosure is considered a useful tool and therapeutic intervention when used with caution. Literature suggests that therapist self-disclosure can be very effective and can, “help establish and enhance a therapeutic relationship, model appropriate disclosure, reassure and support clients, and facilitate gains in insight and action” (Hill & Knox, 2003, p. 538).

Traditionally, therapist self-disclosure was considered an unorthodox practice by the analytic stance. Freud and the classical position warned against the analyst bringing in any of their own needs, inner experiences, and personal beliefs to the treatment. Freud wrote, “The doctor should be opaque to his patients and, like a mirror, should show them nothing but what is shown to him” (Freud, 1912, p. 118). This position reinforces that the therapist ought to have a posture of neutrality, in which their role is to reflect patient projections from a blank screen, and focus primarily on the functional task of interpretation (Farber, 2006; Henretty & Levitt, 2010). Farber (2006) summarizes that three major and ongoing objections to self-disclosure include,

43 1. that it can be harmful to both therapists and clients, 2. that one cannot easily predict the effects of disclosure, and 3. that the motivations for disclosure can be difficult to understand and may reflect an expression of therapist’s needs over client needs.

In a roundtable discussion on the topic, Ted Jacobs (2006) explains that in his experience and training as an analyst, one was meant to be extremely cautious of selfdisclosure of a personal nature. He recalls being told, “the analyst should not be political, because it would expose him or herself to a kind of public scrutiny and a public openness…” (Layton, Hollander & Gutwill, 2006, p. 183). He explains that this resulted in an inhibition that extended outside the therapy room, that clients should not experience therapists marching, protesting, or politically active outside of therapy.

However, despite resistance, the practice of self-disclosure has always existed, even if the psychoanalytic community did not affirm it.

Freud himself was the first violator of his own precepts. The same man who advocated professional distance was also known to show personal pictures to patients, lend books, give gifts, provide financial assistance, chat and gossip about family and colleagues, discourse on art and archeology, conduct analysis in the presence of his dog, and analyze his friends and his daughter (Gay, 1989; Goldstein, 1994; Hill & Knox, 2002; Johnston & Farber, 1996; Lane & Hull, 1990; Momigliano, 1987) (references quoted in text). (Farber, 2006, p. 116) Salvador Ferenzci is credited as having reconsidered concepts of “neutrality” as early as 1932. He conducted experiments in mutual analysis and was an impetus for a movement towards active participation in therapy. (Aron, 1991; Aron & Harris, 2010; Farber, 2006;

44 Sweezy, 2005). Ferenzci objected to the stance of the therapist as withholding. Although his views were considered radical at the time, his work helped to shift the concern of psychoanalysis towards the relationship between patient and analyst. Relational authors note, “Ferenczi's work was largely concerned with the heart of the analytic situation, the relationship between patient and analyst. His discoveries were precisely in those areas that are receiving the liveliest attention among current psychoanalytic theorists and practitioners” (Aron & Harris, 2010, p. 15).

The shifting focus in psychodynamic psychotherapy towards the interpersonal and relational resulted in increasing literature focused on how, what, when and why therapists are revealing to patients. Therapist self-disclosure was more easily accepted as a useful intervention by the humanistic/existential, feminist, and cognitive behavioral schools of thought than psychoanalytic and psychodynamic orientations (Knox & Hill, 2003).

Contemporary theory recognizes, discusses and practices with the subjectivity of the therapist in mind. Psychodynamic therapy in which the therapist is encouraged to be active, engaged, genuine, and to use the data of their own experience requires a constant consideration of the use of self-disclosure. Farber (2006) summarizes that therapists using an intersubjective/relational perspective consider disclosure “on a continuum, ranging from permissive tolerance of self-disclosure to explicit endorsement of all or at least some of its elements” (p. 126).

Some, like Owen Renik (1999) suggest that the analyst out to be, “playing with ones cards face up.” In a 2008 interview, Renik suggests that what makes the therapeutic relationship special is the degree of candor required of its participants.

45 Well, if you’re going to expect that from the patient, the best way to help that happen is for the therapist to be equally candid. The other thing that can be said about self-revelation by the therapist is that the guidelines are not mattes of analytic technique; they’re matters of common sense (Wyatt & Yalom, 2008).

One critique of Renik’s position is that he goes too far in moving the analyst towards a position of collaborator and limits the analyst from being able to see from a third, more reflective position (Bernstein, 1999). Aron (2005) writes about Stephen Mitchell’s concerns that movement towards a contemporary perspective which includes interactive (implicit and explicit) participation by the therapist also exacerbates concerns about excessive self-disclosure.

Boundaries, reality, and neutrality.

Arnold Modell (1989, 1991, 2009) add another dimension to the thinking around use of neutrality and boundaries useful for considering the implications of external realities and politics. He describes the therapeutic setting as an “area of illusion” which is characterized by both reality and symbolism simultaneously. This illusion contained by the frame of the therapeutic process and relationship “can be described as another level of reality” (Modell, 1991, para. 6). Everything that occcurs within the therapy relationship is real, but also occurs in a separate reality from every day life; hence a paradox. The client must move between both realities and be able to see the analyst as a person in real life, inside the special reality of the frame, and as an object for aspect of themselves simultaneously. “One of the functions of the psychoanalytic setting is to set the stage and provide the conditions of safety that will enable the analysand to experience the analyst

46 as a representative for these multiple levels of reality” (Modell, 1989, para. 32). Thus, boundary issues exist in this paradox of realities. Modell (1991) suggests that the therapist must be able to shift between realities with playfulness but that concepts of neutrality help the therapist with the function and maintainance of boundaries. Modell (1991) acknowledges that therapsists are, “no different than individuals in ordianry life in that they experience in relation to their patients the entire gamut of human emotions that are present in any other human affiliation” (para. 9). The paradox here is that while this similarity is consistant with an external reality outside a therapeutic setting, in therapy it occurs simultaneous to and within a setting which is asymetric and has no parallel reality outside the treatment relationship.

What, how, when, why, and how much.

The choice of what to reveal, how much, and when can be challenging and difficult even for experienced therapists. Wachtel (2011) acknowledges that the intimate and personal nature of a therapeutic relationship, which also often is distinguished by deep respect between both parties, is also a limited, professional relationship which is asymmetrical and meant to be focused on the client’s experience. As such, questions about when, what and how to self-disclose ought to be determined on a case by case basis and dependent on the situation between each therapist and client dyad. Henretty and Levitt (2010) review the quantitative research on the topic of self-disclosure and combine the findings with theoretical literature to surmise that non-disclosure is no longer a viable option in many clinical circumstances. There is also a link between self-disclosure and positive outcomes in therapy (Hill & Knox 2001a, 2001b; Henretty & Levitt, 2010). Hill

47 and Knox (2001a, 2001b, 2003) consider that even though therapist self-disclosure is an infrequent intervention, it has a strong effect on clients. They have consolidated several guidelines for best practices with respect to self-disclosure based on the empirical literature on the topic. The guidelines are listed below with emphasis added on those areas that are most relevant to this study.

1. Therapists should generally disclose infrequently.

2. The most appropriate topic for therapist self-disclosure involved professional background, whereas the least appropriate topics include sexual practices and beliefs.

3. Therapists should generally use disclosures to validate reality, normalize, model, strengthen the alliance, or offer alternative ways to think or act.

4. Therapists should generally avoid using disclosures that are for their own needs, remove the focus from the client, interfere with the flow of the session, burden or confuse the client, are intrusive, blur the boundaries, or overstimulate the client.

5. Therapist self–disclosure in response to similar client self-disclosure seems to be particularly effective in eliciting client disclosure.

6. Therapists should observe carefully how clients respond to their disclosures, ask about client reactions, and use the information to conceptualize the clients and decide how to intervene next.

7. It may be especially important for therapists to disclose with clients who have difficulty forming relationships in the therapeutic setting (Knox & Hill, 2001a, p. 416).

These guidelines offer a lens to view subject responses to questions about self-disclosure and offer some base for the practice of self-disclosure, which can be challenging to research, define and describe. Self-disclosure in practice fluctuates by the comfort and

48 experience of the therapist, their theoretical orientation, their previous experiences with self-disclosure, what they were taught about it and how they were supervised. Most therapists very their use of self-disclosure within their own practice (Farber, 2006).

These moment-to-moment decisions are themselves influenced by myriad variables that typically fall somewhere between background and foreground (or conscious and unconscious), including the gender configuration of the therapeutic dyad, the amount of time left in the session, the current emotional state of the patient, and arguably most importantly, the therapist’s clinical instinct as to how this potential disclosure will be experienced by the patient. (Farber, 2006, p. 149) Therapists must consider how to answer direct questions, disclose dilemmas, and use silence. The individual subjectivities and the co-created space between therapist and client contributes to the unique decision by the therapist to reveal in each circumstance.

Bromberg (1994) adds some depth to Hill & Knox’s (2001a) guidelines above by acknowledging that it is the context of the therapy that drives the meaning and purpose of any disclosure.

Like any other choice an analyst makes with a given patient, self-disclosure derives its meaning from the ongoing context of the relationship in which it takes place, not from its utility as a "technique." Its usefulness to the analytic process is organized by the quality of its genuineness as a human act, particularly the degree to which the analyst is free of internal pressure (conscious or unconscious) to prove his honesty or trustworthiness as a technical maneuver designed to counter the patient's mistrust (Bromberg, 1994, p. 540).

49 Immediate vs. non-immediate disclosure.

The nature and extent of self-disclosure is unique to each therapeutic situation.

Aron (1991) suggests that what is most important about self-disclosure is the inquiry by the therapist about the client’s experience of the therapist’s subjectivity and disclosures.

This is backed up in the literature and by the creation of guidelines that suggest that therapist’s responsiveness to clients prior to, during and after a disclosing is an integral aspect of positive outcomes (Henretty & Levitt, 2010; Knox & Hill, 2003; Farber, 2006).

Two categories of therapist disclosure have been identified by the literature; immediate or self-involving and non-immediate or intrapersonal (Audet, 2011, Wachtel, 2011).

Non-immediate disclosure refers to revealing information from outside the session; something about the therapist’s personal life, belief, experience or attitude. A non-immediate disclosure may move the focus away from the client but is also, “used to facilitate rapport, convey human fallibility of the therapist, render the client-therapist relationship more egalitarian and model new perspectives and behaviors” (Audet, 2011, p. 86). Disclosures of a non-immediate nature are more likely to be regarded as inappropriate (Wachtel, 2011). Discussion of non-immediate disclosures includes considerations of ethics and boundaries in clinical practice. The risks here include a possibility of boundary violations culminating to a blurring of roles and shift in the dynamics between therapist and client towards the social rather than therapeutic. This can lead to a situation in which the client feels they must care for the therapist (Audet, 2011, Sadighim, 2014). “This role-reversal would be burdensome to the client who would feel pulled to subjugate his needs to that of the therapist. Alternately, therapist self-disclosure may put the client in a position where he or she censors important information in an effort

50 to not offend the therapist” (Sadighim, 2014, para. 12). This echoes the literature on shared trauma in which therapist and client are simultaneously exposed to an external shared traumatic reality resulting in an acknowledgment of the therapist’s experience outside of therapy and blurring of boundaries. This concept combined with Farber’s (2006) sentiment that a desire to disclose increases with perceived disaster and trauma, leaves open the possibility that in heightened political situations therapist self-disclosure was affected.

Wachtel (2011), in support of this type of non-immediate or intrapersonal disclosure, argues that like a parent-child relationship, no one person can be beyond reproach in their availability to another and absent of needs and feelings of their own. He uses Jessica Benjamin’s work on recognition to reference the idea that there may be value in some aspects of non-immediate disclosure. “The foundations of the capacity both for intimacy and for personal identity require a sense of the parent as another experiencing being and as an active agent with wishes of his or her own” (Wachtel, 2011, p. 275). Is therapist disclosure of their own responses to the socio-political surround considered a non-immediate disclosure? It may depend upon the clinical circumstance, situation, and specifics of the disclosure. It may depend on whether the therapist is responding to the client or to thoughts and feelings of their own or from outside the therapy.

Immediate self-disclosure reflects content revealed that is related to something in the here and now of the session; an occurrence or experience of the therapist, particularly in response to the client and a feeling related to the happenings in the therapy (Wachtel, 2011). Immediate therapist self-disclosure is also described as self-involving and is more often defined as a countertransference disclosure; sharing of immediate or past feelings

51 possibly in response to and interaction with the client in the moment. This greatly differs from a self-disclosure of a non-immediate nature. Much of the analytic relational and intersubjective literature refers to a self-involving therapist disclosure as one that allows the dyad to more deeply understand unconscious communication between them (Ehrenberg, 1995, 2010). For relational/intersubjective work, the therapist’s role is to “monitor” and “use” the impact and effect of such participation, not to avoid participation.

Thomas Ogden’s (1997, 2004) work offers another example of how psychoanalysis works with intersubjectivity in the therapeutic dyad and specifically with disclosure. Ogden uses the concept of “reverie” as, “a process in which metaphors are created that give shape to the analyst’s experience of the unconscious dimensions of the analytic relationship” and that in the uniquely individualized experience between that therapist and client, is a “pool of unconscious experience” in which they both contribute (Ogden, 1997, para. 43). This concept of reverie sets the stage for Ogden’s (1997) discussion of how he shares with clients in therapy. He wrote, When I speak to a patient about what I think is going on between us, I attempt to speak from my experience in (and of) my reverie experience as opposed to speaking to the patient about my reverie experience. What is of value to the patient is not an account of what the analytic relationship (including the leading transference-countertransference anxieties) feels like to me, but what the relationship and its attendant anxiety feels like to him and how that experience relates to other experiences (both real and imagined) that he has had with me and with other people in the course of his life. (para 43)

52 Ogden (1994, 2004) explains the concept of the “analytic third” as the unique space and activity that is created between the unconscious intersubjective experience of the therapist and analyst. The analytic third is a concept that allows the therapist to use reverie to be in touch with the conjointly created space to better understand the client’s needs, wishes, feelings, somatic states, and inner life. Ogden (2004) explains that, “experiences in and of the analytic third often generate a quality of intimacy…” (para.

44). Ogden suggests that a therapist’s internal acknowledgement of their state, sensations, and experience will allow them to better attend to and respond to clients in session.

Aron (2006) suggests that self-disclosure can be used as an attempt to create a third point of reference. This concept of “the third” differs from Ogden’s (1994, 2004) but, may offer some use in discussion of the political and psychotherapy, particularly in terms of divergent ideologies or conflicting opinions. Aron (2006) discusses a case example from a supervisee in which the therapist felt horror and disgust at her client’s aggression and callous reaction to the September 11th attack in New York. In the discussion, Aron explains that developing a space that can allow for identification with the client without the therapist losing her own perspective can be productive. “Certain forms of self-disclosure are best understood as attempts to create a third point of reference, thus opening up psychic space for self-reflection and mentalization” (Aron, 2006, p. 350). This “third” space allows the opportunities to discuss and consider diverging experiences and meanings between the therapist and client. “Conceptualizing the third is one attempt to move beyond such oppositions and to create triangular space within which psychoanalysis too can think more freely, open dialogue, grow, and

53 develop” (Aron, 2006, p. 366). These techniques are all ways that therapists manage the use of immediate self-disclosure in therapy.

How therapists conceptualize and respond to politics.

Social work and psychodynamic therapists and analysts are often perceived as professionals in a left leaning profession (Tolleson, 2013, Layton, Gutwill & Hollander, 2006). However, as part of the roundtable discussion documented by Layton, Gutwill & Gollander (2006), Wachtel offers a reminder that although the profession is liberal in their views the profession is conservative in that change happens slowly, it is historically organized around a main hierarchical figure, and psychoanalytic technique is very traditional in nature. It is not necessarily a given that psychotherapists will consider politics in therapy or that clients will consider bringing political material to session. In the same conversation, Jacobs (2006) notes, “Very rarely have I entered into a political discussion with a patient” (p. 170). He reports that it seems therapists and patients avoid the exploration of politics in therapy, explaining, “both people may be wary of entering into a situation in which very strong and sometimes quite irrational feelings will enter into it” (p. 170). Discussion of therapist self-disclosure crosses over into literature that explores the use and acknowledgment of the political in psychotherapy. The literature below highlights the discussion of concepts of “inner” vs. “outer” and how this is seen, used and conceptualized by therapists and in treatment as well as how self-disclosure may be a part of treatment.

Layton (2006) suggests that a result of our cultural normative process in the United States was an effort to enhance individualism, capitalism, and self-reliance which

54 works to “unlink” the psychological from the social. This is also echoed by Cushman’s (1995) view that the context of the values of individualism and consumerism create an “empty self” in which psychotherapy continues to feed in its disconnect from the political (Cushman, 1995, Avissar, 2016). Layton (2006) suggests that political and civic development ought to be considered in therapy and she further wonders if shared conflicts around the personal and political are played out unconsciously between therapists and patients (p. 110). Layton writes about political material that a client brings in via a dream. She explains that both patient and therapist are anxious about exploring political themes and using therapy correctly: …I found myself struggling throughout the session against the urge to close off this inquiry with an interpretation that would reduce what she was saying to the kind of psychological insight that separates the psychic from the social. Granted, we are living in difficult political times, times in which historical events such as September 11 force their way into the consulting room. But this experience revealed to me my own resistance to linking the psychic and the social, a resistance of which I was largely unaware. Fighting my urge to interpret enabled the two of us to discover that there are realms beyond those of work and love that are clinically relevant (Layton, 2006, p. 110).

Billie Lee Violette (2013) asks questions that allow the therapist to consider both verbal and non-verbal aspects of self-disclosure as it relates to politics, “what do we represent to the patient when war and current culture seep into our pre- and subconscious minds? Do the accoutrements of our offices and our lifestyle represent democratic philosophy or social justice or that of success and consumerism?” (p. 78). Violette (2013)

55 suggests that adhering too rigidly to theory can make it difficult to meet the client and her needs and can risk an exclusion of the outside world. She acknowledges there are times to bring in external reality as opposed to avoiding it and further exemplifies her point using a vignette in which her client asks her directly who she is voting for in the 2008 presidential election. At first, she did not answer directly, but was left feeling regret after the session so when the client pressed her weeks later, she disclosed who she was voting for and why. This vignette explores the complexities of this specific case and the therapist’s sense that the client “needed something real” but, that the disclosure also exposed the client to the therapists, “own anxieties about the political situation, but we were in it together” (p. 82). Violette (2013) suggests that training ought to consider “our cultural embeddedness so that we might be able to find some ways to connect the psychoanalytic understanding of the person (awareness of the unconscious) to the ethical questions of being a person in the larger world” (p. 82).

In the roundtable dialogue between Neil Altman, Jessica Benjamin, Ted Jacobs, Paul Wachtel the question of self-disclosure is posed (Layton, Hollander, & Gutwill, 2006). The discussion is lengthy and covers more than self-disclosure, but it is noteworthy that the topic is discussed within the chapter titled, “IV: The Last Taboo?” highlighting a common refrain in the literature that politics as a topic is often seen as prohibited (Avissar, 2016.) During the discussion, Altman (2006) notes that politics feels for him like slippery slope, an area in which one can enter with benevolent intentions, but can result in feeling angry or shutdown. Wachtel agrees, adding that for him it is less challenging to work with a client with opposing views to the “right” because it is easier to maintain a sense of neutrality. Wachtel maintains that those clients who are further to the

56 left politically than him leave him feeling more challenged as, “in many ways they are closer to my own ideal than I am, and I can feel guilty.…” (Layton, Hollander, & Gutwill, 2006, p. 180). He goes on to explain that his self-representations can be threatened by these clients. Jacobs expresses curiosity about work with clients who share similar political views. He wonders if the agreement about issues can become a collusion, “in the sense that we both sort of signal we won’t get into the dirty or the difficult, the most painful areas of life, or areas of disagreement, where we may really find ourselves in a certain kind of conflict” (Layton, Hollander, Gutwill, 2006, p. 187). He notes that politics may be an area which is easy to avoid.

During the conversation, Benjamin, Altman, and Wachtel all acknowledge that their clients may come to them already aware that their therapist has political leanings because of the stance of their published work. Benjamin explains, My patients talk about their political views with me constantly, and they know what my political views are, whether I tell them or not, and that has to do with my style, my reputation my writings.… Anybody who’s inside my cultural world can tell what my politics are. I am totally legible to them, within a certain framework, though, of course, they don’t know the specifics. (Layton, Hollander, & Gutwill, 2006, p. 171) And, while Benjamin acknowledges that this may be why some people choose to work with her, she would differentiate this from someone who has a need in their session to vent and discuss some political event or article that they have just read about in a newspaper. “They’re just in a rage about the current political situation. I try to see what the latent content of that is....” (Layton, Hollander, & Gutwill, 2006, p. 184). Altman

57 (2006) pointed out earlier in the roundtable, “That a political discussion- could have latent meaning at some psychological level, but it could be the other way around, too, whereas something that’s not manifestly political could be latently political” (p. 171).

Here he goes on to talk about the sociocultural unconscious and how individuals are organized by these factors.

Inner vs. outer.

In chapter 6 of the volume titled, Psychoanalysis, Politics, and Class, (2006) Gutwill & Hollander write of the importance of psychotherapists to consider public events as client concerns and not only as symbols or references to unconscious conflicts with roots in relationships to others. Gutwill and Hollander are described here as making, “an argument for contemporary psychoanalytic treatment to allow one’s relationship to the social reality, rather than interpreting it as a displacement of a symbolic reference to unconscious conflicts found in earlier relationships” (Redding, 2008, p. 318). Ruderman and Tosone’s (2013) edited volume, Contemporary Clinical Practice: The Holding Environment Under Assault, suggests therapists and clients cannot ignore the reality of what occurs outside of therapy during the psychotherapy hour and that current events function as an assault on the holding environment of the clinical hour. In 2008, the American Association of Psychoanalytic Clinical Social Work (AAPCSW) met to address questions about how to tackle and consider existential anxiety in treatment; asking if the “outer” world can be acknowledged and addressed while still considering the “inner” world of the individual. They concluded that what happens outside of psychotherapy cannot be ignored. Ruderman (2013) describes what happens in the clinical work:

58 I have never had as many patients who need to talk about the enormous intrusions and incursions assaulting them from the outside. Delaying their usual focus on their present emotional dilemmas and their past disappointments and deprivations, many patients now choose to begin sessions by focusing on economic distress, the political scene, and other existential insecurities and anxieties by which they feel assaulted. (p. 5) Her statement exemplifies that dealing with external social and political issues in psychotherapy is not new and not only specific or tied to the most recent Presidential election. Ruderman (2013) expresses curiosity about how to maintain authenticity and preserve neutrality for client feelings while simultaneously noting the impact of client and clinician reactions to all sorts of “outer” realities; global warming, health care, the economy, social policies and global threats. “There is no analytic interpretation that quells the internal anxiety of both patient and analyst when we are dealing with real threat in a society that offers insufficient care” (Ruderman, 2013, p. 4).

Ruderman (2008) bridges this literature to the literature on shared trauma (see section on shared trauma) by asking, “How can we engender awareness of the enormity of the world outside, the political and societal forces which leave all of us, since 9/11, in a state of collective PTSD, and offer a way to deal with the chaotic world in which we live” (p. 208). In the same 2013 volume, Benitez-Bloch writes, “In treatment, we try to create, for both the clinician and the patient, a space and a process to help us live and struggle with the paradox of being an individual and also a member of society. We want our work with patients to inform us so that we feed into our professional affiliations to link our knowledge base and our clinical experience with social policy as steps toward

59 dissolving the paradox between inner and outer worlds” (p. 39). Benjamin (2006) adds that politics is taboo, “because it’s really about the outside. It’s really about something outside the consulting room, and, for so long, psychoanalysis denied this” (Layton, Hollander, & Gutwill, 2006, p. 182).

The concepts and ideas highlighted above move us naturally to look at the literature on shared trauma and shared reality. But, first we will turn to a brief review of Neurobiology and Affect Regulation as it is impossible to consider situations of heightened affect and intersubjective/relational encounters without acknowledging a model that will assist in elucidating the processes occurring in the individual or the therapeutic dyad.

Neurobiology and affect regulation.

Regulation and neurobiological theories add depth to our potential to understand political material in psychotherapy sessions, particularly considering the intrusive nature of news and social media and the experience of national or collective trauma (see section on national trauma). Since these theories are complicated and dense, the section below will only highlight aspects that are most relevant to the project at hand.

Regulation theory, “proposes that the regulation of affect is fundamental to the organization of body mind and thus for adaptive functioning and subjective experience” (Hill, 2015, pp. 27–28). If regulated affect is a key to functioning well, and if reports of dysregulated affect increase after politically charged moments in time, then the connection between how we process socio-political material and its impact on affect regulation is relevant to this exploration. Understanding the possible psychobiological

60 process that may occur when one is heightened or dysregulated may contribute to deeper understanding of what occurs during relational encounters as Schore and Schore (2008 explain, …at the most fundamental level, the intersubjective work of psychotherapy is not defined by what the therapist does for the patient, or says to the patient (left brain focus). Rather, the key mechanism is how to be with the patient, especially during affectively stressful moments (right brain focus). (Schore & Schore, 2008, p. 17) Stephen Porges’ (2017) research and theories focus on, “how neural regulation of physiological state influences behavior and how these mechanisms are related to how we interact socially” (p. 215). Porges’ (2009, 2011) Polyvagal theory links the influence of the central nervous system on the autonomic nervous system and explains the coordination that occurs between in the human body between behavior, physiology, and affect. “Within this model, how we look, listen, and vocalize conveys information about whether we are safe to approach” (Porges, 2017, p. xvi). Our nervous systems are regulated in the context of our relations to others. The Polyvagal theory proposes that safety and trust is necessary for optimal nervous system functioning. According to Porges (2017), in order to feel safe, three conditions must be present simultaneously; 1. The autonomic nervous system must not be engaged in a defensive state, 2. The social engagement system must be activated to contain and manage arousal of the sympathetic nervous system and, 3. Cues that offer and support growth can be detected through a process called neuroception (p. 23-24.). Porges’ (2017) argues that the concept of how, when, by whom, and what type of safety is offered, ought to be reconsidered.

61 The theory forces us to question whether our society provides sufficient and appropriate opportunities to experience safe environments and trusting relationships. Once we recognize that the experiences within our societal institutions such as schools, hospitals, and churches are characterized by chronic evaluations that trigger feelings of danger and threat, we can see that these institutions can be as disruptive to health as political unrest, fiscal crisis or war. (pp. 44-45) Porges (2017) theory explains that individuals use social relationships to “coregulate our behavior and physiology” (p. 51). Schore & Schore (2008) explain that although regulated and dysregulated states of arousal are initially responded to and repaired by caregivers, in ideal relationships, individuals eventually develop a capacity to self-regulate in relation to others and auto-regulate on their own in response these early experiences (Schore and Schore, 2008, Palambo, Bendicsen & Loch, 2010). The therapy relationship offers opportunities for individuals to continue to reorganize their primary affect-regulating system and develop more secure internal working models (Hill, 2015).

However, does the opportunity for therapists to offer safe, engaged, regulated, implicit interactions become impaired if the therapist is activated by similar dysregulating external stimuli?

Dysregulating events within psychotherapy and in the external environment occur for both therapists and clients. Hill (2015) notes, “Affect regulation therapy must be adjusted to the emotional capacities of each patient according to the emotional capacities of each therapist. (See Schore, 2003b, Appendix)” (p. 197). Schore (2003a, 2003b, 2011a, 2011b, 2012) identifies that the emotional communications and affect regulation occurs

62 on a psychobiological level from right brain-to-right brain. Relational psychoanalyst, Philip Bromberg (2011) integrates neurobiology and affect regulation concepts with relational psychoanalytic theories in his work, highlighting “the dual role of the analyst as psychobiological regulator and co-participant, and that this duality is especially vital during heightened affective moments” (p. 120-121) Ilene Philipson (2018) notes her concern the profession does not consider the trauma of the client’s environment as something experienced by analysts as well. She explains that the events of Trump’s election and aftermath have left therapists, “experiencing greater clinical symmetry as co-participants” (Philipson, 2018, p. 3). “The boundary lines between analyst and patient narrow as we all are subject to a powerful sense of foreboding and insecurity about the future” (Philipson, 2018, p. 3). Philipson’s (2018) ideas fit into the section of this literature review on shared trauma, however, they are used here to highlight questions about affect regulation. How is the safety of the therapeutic environment and the regulated space offered by therapists impaired or changed by the impact by external heightened events on the therapists themselves?

Shared reality and trauma, collective and shared traumatic reality.

Man-made traumatic experiences and natural disasters have prompted the field of psychology and social work to examine crisis circumstances and experiences shared by both therapists and clients. This literature traces the history and changing definition of such a phenomenon using the terms, “shared trauma,” “shared traumatic reality,” and “shared reality” to describe the collective experiences and exposure to trauma by both parties in the therapeutic dyad (Baum, 2010, 2012, 2014; Baum & Dekel, 2010;

63 Benyakar, Baruch, Kretsch & Roth, 1997; Bauwens, Glassman, & Tosone, 2014; KeinanKon, 1998; Tosone, 2011; Nuttman-Schwartz, Stephens, & Tosone, 2012). Understanding these concepts as different from other trauma-related concepts such as vicarious traumatization, compassion fatigue, secondary traumatic stress or countertransference is useful and acknowledges the impact of a simultaneously shared traumatic experience; i.e. living in a war zone, experiencing consequences of single or continuous terror attacks, surviving natural disasters like hurricanes or floods. (Dekel & Baum, 2010; Baum 2010).

The construct is meant to capture the dual nature of the personal and professional impact for the therapist of being a member of the same community that has been impacted by a trauma. Literature in this area encompasses considerations of impacts on treatment, potential professional growth, and the positive and negative impact of shared traumatic reality (Dekel & Baum, 2010; Baum, 2014). A brief account of the development of these constructs, major contributions, as well as the connection of these concepts to the therapeutic relationship and clinical work are highlighted below.

Baum (2010) details the development of shared reality concepts in the literature noting that Metta Schmideberg (1942), Melanie Klein’s daughter, is first referenced as acknowledging the impact that communal disasters can have on professionals. In Schmideberg’s article, she discusses the impact that the London Blitz bombings had on her clients and recognizes that she was impacted as well. Baum notes that in 1952, sociologist, Killian, wrote about community disasters and the experience of having two roles in response; one personal and one in which there exists a responsibility to the community. Baum (2010) explains that these two articles function as the first citations of the acknowledgement of shared trauma. Schmideberg looks at the “joint exposure of the

64 client and psychotherapist to the same disaster” while Killion considers the “professional’s double exposure, as a professional and individual” (Baum, p. 250).

Shared reality.

After the Gulf War in Israel, Benyakar, Barauch, Kretch & Roth (1997) first use the term “shared reality” to describe the experiences of therapists working with evacuees (p. 32). A core concept of shared reality is the understanding that reality affects all of those involved in the therapeutic process. Benyakar, Barauch, Kretch & Roth (1997) explain that psychotherapy during and after the Gulf War in Israel was not exempt from the impact of events occurring in real life. The clinical process could not ignore external reality. “When we as therapists, turn a dialogue initiated by the patient about a terrorist attack into a discussion of the impulses and fears he/she is expressing, we often miss the true connection between the threatening external realities and the psychic reality” (p. 31).

Shared traumatic reality and shared trauma.

Keinan-Kon (1998) is first credited with use of the term “shared traumatic reality,” writing, But what happens when external reality is particularly compelling? When analyst and patient alike would seem objectively to be sharing the same experiences of a life-threatening situation? It is essential to examine and conceptualize the impact of another reality on the analytic pair, the reality of social catastrophe that is external but common for both of the protagonists of the analytic situation. The nature and quality of the connection between internal world and external reality

65 becomes even more complicated during times of real threat. Under such circumstances, the meeting between the inside and the outside changes (p. 419).

Therapists and analysts who experienced the impact of 9/11 directly have used the term, “shared trauma.” This terminology reflects a change in the literature towards a perspective that considered both the personal and clinical impacts of real lived and shared experiences and included the perspective of the therapist simultaneous to the client as well as in relation to the client (Baum, 2012). These shifts mark therapist recognition of the reality of shared trauma for themselves personally and professionally, and acknowledgment that they must be cautious not to pathologize client reactions and responses to trauma (Seeley, 2005; Tosone, 2006). Seeley (2005) notes that in the aftermath of 9/11 therapists recognized that interpreting patient’s political comments as representations or resistances seemed wrong and thus allowed for a more open dialogue of political content in sessions.

Research.

Research studies looked at the impact of shared trauma on social workers impacted by events such as 9/11, conflicts in Gaza, and Hurricane Katrina (Baum, 2014; Tosone, McTighe, Bauwens, & Natuarale, 2011; Tosone, McTighe, Bauwens, 2015).

Posttraumatic growth, a concept characterized as “positive psychological change experienced as a result of the struggle with highly challenging circumstances” is tied to increased appreciation for life, more meaningful interpersonal relations, changed priorities, and perceived increases in strength and a deeper awareness of an existential or spiritual life (Tedeschi & Calhoun, 2004a, 2004b; Ramos & Leal, 2013). Bauwens and

66 Tosone (2010) looked at the long term personal and professional impact of 9/11 on clinicians who lived and worked in the context of collective trauma and described positive gains as well as negative effects for clinicians. Tosone (2006) correlates posttraumatic growth for clinicians as one possible result of experiencing shared traumatic reality with clients. An important aspect of posttraumatic growth is that it is not exclusive of distress or suffering and, “posttraumatic growth does not necessarily yield less emotional distress,” but can occur as a result of struggling and coping. (Tedeschi & Calhoun, 2004a, para. 6).

Confirming the construct of shared traumatic stress.

Tosone, McTighe, Bauwens, & Natuarale (2011) and Bauwens, McTighe, & Tosone, (2015) studied the impact of traumatic events on social workers after 9/11 and Hurricane Katrina to operationalize shared traumatic stress (STS or SdTS) as a construct that is measurable. The role of resilience was studied in terms of how it intervened to reconcile risk factors with shared traumatic stress. The findings for the 9/11 social workers showed that insecure attachment, the events of 9/11 and exposure to other traumatic events can predict increased traumatic stress (Tosone, McTighe, Bauwens, & Natuarale, 2011). Overall the findings enforce “discovery of a similar relationship between the independent variables and SdTS in both the 9/11 and Katrina studies suggests a consistency to the phenomenon of SdTS that applies to both man-made and natural disasters” (Tosone, McTighe, & Bauwens, 2015, p. 1324).

Baum (2014) studied the impact of shared exposure on Israeli social workers in the context of missile attacks in the Gaza war. There are features of a clinician’s “double

67 exposure” (personal and professional to trauma) that differ from an exposure that is only personal or only professional (Baum, 2010, 2014). These features are, “intrusive anxiety, lapses of empathy, immersion in professional role, role expansion and changes in place and time of work” (Baum, 2014, p. 2113). Findings show that the double exposure of social workers contributed to both distress and growth. Of note is that only lack of empathy was not found to correlate to personal growth for the clinicians while lapses of empathy, intrusive anxiety, and changes in the time and place of work added to the social worker’s distress (Baum, 2014). Baum (2014) concludes that, “further study of professionals in other situations of double exposure is recommended” (p. 2128).

Limitations of this study include the small sample, lack of validation of the instrument used for assessment, and lack of data looking at vicarious exposure to compare with double exposure, as well as that it looks only at the man-made trauma of war.

Baum (2010) notes that further research might help to better understand the impact and experience of “different types of shared traumatic realties on different types of helpers and in different phases” (p. 258). This is important for the purposes of this research because the literature leaves unanswered if the events of the 2016 presidential election and ensuing Trump presidency qualifies as a “shared traumatic reality” or “shared trauma.” While it was a collective experience it was not traumatic for all involved and it includes a subjective evaluation and personal response that is not necessarily universal (i.e. for some the election may have been exciting, wonderful or positive, or others neutral). So, what is the impact on the therapeutic relationship during times of a national trauma?

68 Impact on Clinical Work and Posttraumatic Professional Growth First person narratives by clinicians after Katrina capture a sense of enduring personal and professional change that can occur as a result of a shared traumatic reality.

“I am not the same person I was before the storms and neither am I the same psychologist (Matthews, 2007, p. 327). A group of psychologists describe enduring chronic distress personally and observing in themselves a sense of shared experience with their clients after the Hurricane (Abrahams, J., Bellando, B.J., Black, F. W, Faust, D.S., & Warner, M.S., 2008). Bauwens and Tosone (2010) found that post 9/11 clinicians reported that the experience was the impetus for changes to their clinical practice. Positive changes included “increased compassion and connectedness with clients” (p. 498). Negative effects of shared trauma were reported as well; increased vulnerability, feeling illequipped for the situation and critical feelings about outside organizational responses. A group of psychoanalysts (Nunberg, Dahl, Herschkowitz, Kantrowitz, Neubaure, Orgel, Basch, & Fogelman, 2011) reflect on the significance of the patent and analyst sharing the same experience (9/11) and explore the relationship between current external shared events and the possible intrapsychic experience of their patients. They too, note the disruptions in the frame, boundary shifts, and changes in the therapeutic relationship as inevitable; that sharing the experience affected the treatment. As analysts focused on discussion of the intrapsychic world of the patent, they acknowledge that shared events may lead to non-interpretative interventions in treatment and warrant a review of theoretical formulations with attention towards collective reality and its interaction with intrapsychic life. (Nunberg, Dahl, Herschkowitz, et. al., 2011).

69 Unique aspects of clinical work have been noted to occur under the circumstances of shared reality, including a “trap of conflicting inner needs,” (Baum, 2012, p. 37), “enhanced therapeutic intimacy… boundary alterations,” (Tosone, Nuttman-Schwartz, & Stephens, 2012, p. 232) and blurred boundaries both within the therapist (between their personal self and professional self) and within the therapeutic dyad (Baum, 2010, Baum & Dekel, 2010).

The trap of conflicting inner needs.

Baum (2012) uses the concept of “trap of conflicting inner needs” to describe an intra-psychic conflict that occurs for clinicians in circumstances of shared trauma. Baum (2012) asserts that the experience of shared trauma creates an inner angst within the practitioner around mortality and to cope with this, clinicians distance themselves from clients resulting in impaired empathy. This perceived decrease in empathy exacerbates shame, guilt and distress for the clinician; thus, a trap of conflicting needs. “The trap of conflicting needs stems from the heightened mortality salience that occurs in the wake of experiences or events that stimulate thoughts of death and augmented death anxiety” (Baum, 2012, p. 39). Baum (2012) refers to Tosone’s (2006) writing in which she discusses her anxiety about attentiveness and distance with her clients. Further exploration and research is suggested by these authors to better understand more about empathy and regulation of emotion in the context of shared trauma.

“Blurred boundaries,” self-disclosure, and “therapeutic intimacy.”

Tosone, et.al, (2012) elaborates on “shared trauma” more specifically by examining its impact on the clinical relationship, therapeutic process, and the

70 psychotherapist. She examines the impact that shared trauma can have on boundaries and self-disclosure between therapist and client, “When the clinician and client are exposed to the same collective trauma, however, self-disclosure may be a moot point as the client is aware of the clinician’s exposure to the community-based disaster” (Nutmann-Schwartz, Stephens, & Tosone et al., 2012, p. 233). Self-disclosure is inevitable when the reality exists in the public domain. Post 9/11, Tosone (2011) describes her own experience with intimacy, “To maintain a traditional therapeutic stance at that time seemed inauthentic and intolerable. I found myself engaging on a deeper level of therapeutic intimacy” (p.

26). Tosone and her collaborators acknowledge that in this context the frame is breached and so is the illusion of distance between the professional and personal. If the therapeutic relationship is a major factor in healing, then authentic intimacy and closeness in times of trauma may be necessary (Tosone, Nuttman-Schwartz, & Stephens, 2012; Tosone, 2006, 2011).

Tosone, Nuttman-Schwartz, & Stephens (2012) use two narratives to illustrate issues with self-disclosure and boundaries; one written by an intern working in NYC post 9/11, and the other a clinician in Israel working in a community faced daily with rocket attacks. The 9/11 narrative exemplifies that shared trauma can heighten and strengthen therapeutic intimacy and this shared experience can have a transformative (positive) impact on the treatment.

While there can also be a blurring of boundaries in these situations that can impede the work, it is also possible to harness these relational exchanges to benefit the treatment. In this situation the clinician no longer maintains a superior role but opens up a space, to the “intimate edge” what Ehrenberg (1992) described

71 as the clinician being acutely aware of the subtle changes that are happening in both the clinician and client. (TS in Tosone, Nuttman-Schwartz, & Stephens, 2012, p. 235) The author of the vignette understands and visualizes with familiarity and intimacy what the client is describing. A second narrative exemplifies that in times of a shared traumatic reality positions or boundaries in the therapeutic frame can become reversed. For example, there can be moments in which the therapist may have great needs, vulnerabilities or overwhelming concerns related to the shared reality outside of the therapy. The client might step in, either to comfort the therapist or take care of the dyad.

In the vignette example, the therapist acknowledged the shift and returned to role of therapist with a resolution that allowed the client and therapist to deepen their acknowledgement that they were, “in the same boat,” in relation to the traumatic reality surrounding them (Tosone, Nuttman-Schwartz, & Stephens, 2012).

Baum (2010) also furthers the discussion about the connection between shared traumatic reality and the therapeutic relationship by differentiating between emergency response work and ongoing psychotherapy. In ongoing psychotherapy, blurred boundaries within the therapeutic dyad and blurred boundaries within the inner dialogue of the therapist are both affected. The therapist’s internal personal and professional self is blurred.

A communal disaster may affect the ongoing relations between psychotherapist and client in several ways. First of all, psychotherapist and client may find themselves responding to and working through the disaster at much the same time, so that clients’ references to the disaster may arouse strong

72 countertransference in the psychotherapist. Moreover, many psychotherapists who experience the same communal disaster as their clients have a feeling of “being in the same boat” with them (Tosone & Bialkin, 2003)—an awareness that creates new dynamics both in the therapeutic relationship and in the psychotherapist’s self. (Baum, 2010, p. 254) If indeed, the current socio-political issues in the US qualify as a national trauma, then we need to understand the impact of the shared trauma on the therapy relationship and have some compass for therapists to understand any changes in boundaries and the therapeutic frame this might create. Tosone says, “Personally, I have learned that the demarcation between the personal and professional realms is, to a considerable extent, arbitrary when facing extraordinary times” (Tosone, 2011, p. 29).

National Trauma and Cultural Trauma National trauma.

Social psychologist Arthur G. Neal (1998) defines the concept of a national trauma. “In the final analysis, however, the test for a national trauma is that of the disruptive effects of an extraordinary event on the institutional underpinnings of the social order” (Neal, 1998, preface, xi). Neal examines eight case examples of national trauma including the Great Depression, the attack on Pearl Harbor, Communism, the assignation of President Kennedy and Martin Luther King Jr., the Vietnam War, Watergate, and technological accidents. He describes that national trauma includes, “individual and collective reactions to a volcano-like event that shook the foundations of the social order” (Neal, 1998, preface, ix).

73 Shock, disbelief, disruption and out of the ordinary events that capture the attention or are considered disturbing to major groups are aspects of “national trauma.”

How situations are experienced and recalled also contribute to the conditions of national trauma. Neal’s definition, cited in chapter one, seems to fit with the experience some have described during and after the 2016 election of President Trump, in which integrity of values and systems are questioned and there is a disruption from normal every day events (Neal, 1998, p. 5). Of specific note, Neal discusses that elected officials are, “caretakers of the nation, and their actions and decisions symbolically represent the agenda of the nation” (Neal, 1998, p. 11). He uses the Watergate affair to describe the disbelief and denial that existed when Nixon was charged.

As one of the primary living symbols of the nation, the presidency and its occupant are important ingredients of society as moral community. The president speaks on behalf of the nation, represents the nation on ceremonial occasions, and occupies a primary position of trusteeship. (Neal, 1998, p. 32)

Impact of national trauma.

A national trauma creates connections between the personal and the historical, forcing individuals to cope with changing conditions in society (Neal, 1998). Coping with societal changes, responding internally, and collectively assigning meaning to social events are part of the response to national trauma. Collective traumas also have an impact on national identity; they can fragment or alienate groups or bring groups together.

Historically, national and collective trauma become events with social significance, in which causes, conditions and consequences are recurrently debated. Personal memory

74 and collective memory, enhanced by recorded history, is determined in part by filtering experience. Stories of national trauma are reminders of mistakes. Neal (1998) notes, “National traumas also provide the raw material for shaping national identities and revitalizing values for promoting the collective good” (p. 203).

Cultural trauma.

Alexander, Eyerman, Giesen, Smelser, & Sztompka (2004) use the term “cultural trauma” to explain collective psychological experiences. They assert that trauma work and theory play a key role in defining the origins and outcomes of critical social conflicts, noting that even events that are currently thought of as deeply traumatic for civil society may not inherently devastating, but are constructed as traumatic through cultural processes’ including memory.

Alexander (2004) describes cultural trauma as a scientific concept which connects social responsibility, political action, and perceptions of events by collective groups who perceive their experience as traumatic, and share in the suffering together. He explains, "Cultural trauma occurs when members of a collectivity feel they have been subjected to a horrendous event that leaves indelible marks upon their group consciousness, marking their memories forever and changing their future identity in fundamental and irrevocable ways" (Alexander, 2004, p.1).

Drawing from trauma theory, cultural trauma includes, “naturally occurring events that shatter an individual or collective actor’s sense of well-being.” (Alexander, 2004, p. 2). Alexander (2004) and Neal (1998) explain that the quality of the event itself plays a role in traumatizing the collective. Aspects of cultural trauma, like that of national

75 trauma, include shock or outrage and feels out of the ordinary to a group (Alexander, 2004). Psychoanalytic thinking contributes to the concept of cultural trauma through concepts such as defenses, unconscious emotions, and cognitive distortions; highlighting repression and memory and ongoing feelings, behavior and responses to the trauma both in response to the experience, as well as the process of repressing aspects associated with it. Memory and repression that contribute to cultural trauma.

Alexander (2004) ties trauma with memory and identity; noting, a revision of identity takes place when traumas are experienced and represented by a collective group.

“By allowing members of wider publics to participate in the pain of others, cultural traumas broaden the realm of social understanding and sympathy, and they provide powerful avenues for new forms of social incorporation” (Alexander, 2004, p. 24).

Alexander (2004) also notes, not all disruptions are traumatic.

For traumas to emerge at the level of the collectivity, social crises must become cultural crises. Events are one thing, representations of these events quite another.

Trauma is not the result of a group experiencing pain. It is the result of this acute discomfort entering into the core of the collectivity’s sense of its own identity. (p.

10) The media plays a role in cultural trauma. Media, social media and the population’s responses to media have been a factor in current cultural trauma of 20162019. “Mediated mass communication allows traumas to be expressively dramatized and permits some of the competing interpretations to gain enormous persuasive power over others” (Alexander, 2004, p. 18). So, depending upon which news channel one watches, who they follow on Twitter, which sources sound as alerts on the phone, and what one’s

76 friends are posting on social media, there is risk of being inundated by distorted or exaggerated “news.” Alexander also notes that when the media reports about traumatic events and established facts about the trauma they (the media themselves) may become under attack from those who are perceived as the perpetrators. We, of course see this happening with Donald Trump and his attacks on media, calling them “fake news,” attempting to discredit them, threatening them. Further, Alexander notes that when governmental powers create special commissions, investigations, and inquiries this is an indication of a trauma process at play.

In the same volume, Smelser (2004) suggests in Chapter 2, that understanding psychological trauma and stress allows deeper insight about cultural trauma. He uses Freud’s early work as a starting point for discussion of how trauma becomes repressed and later converted into symptomology as an effect of the “fright.” He notes inclusion of context into an understanding of trauma helps the discussion of cultural trauma, as events that seem like they might automatically qualify as cultural trauma, only meet the criteria because of how they are experienced and remembered. Smelser (2004) notes that for an event to qualify as a cultural trauma, It must be remembered, or made to be remembered. Furthermore, the memory must be made culturally relevant, that is represented as obliterating damaging or rendering problematic something sacred – usually a value or outlook felt to be essential for the integrity of the affected society. Finally, the memory must be associated with a strong negative affect, usually disgust, shame or guilt. (Smelser, 2004, p. 35)

77 He asserts cultural traumas, “are for the most part historically made, not born” (Smelser, 2004, p. 35). He goes on to explain that to be described as a cultural trauma, the event must disrupt the culture and culture here is defined as concepts that link groups (values, norms, knowledge, outlooks, beliefs, language, meanings). In American history, the institution of slavery, The Great Depression, and the history of oppression of Native American lands are three examples given by Smelser of cultural trauma. Smelser connects concepts of psychological trauma and stress to look at mass coping, collective coping, collective repression, identity, blame, scapegoating, and ambivalence (versus attraction or revulsion) in the context of cultural trauma.

These ideas fit in with Cushman’s (1995) writing about the hermeneutic and constructivist thinking in psychotherapy; understanding everything in light of the times in which it occurs. “Philosophical hermeneutics helps us learn more about the power of the political structures of our landscape, and how that power shows up in a particular shape as a result of the moral understandings that frame that landscape” (Cushman, 1995, p.

348). The literature on national trauma and cultural trauma help fame the context of the reality for groups and collective identities at any given time. Not all peoples must share the same experience for the situation to be traumatic but, some cultural groups do need to feel something conjointly. This is useful in understanding that not all therapist/client dyads have to share the same ideology to be experiencing the impact of a cultural trauma collectively. There is not a question that the campaign, election and subsequent Presidency of Donald Trump has created a sense of national and cultural trauma for many. Others may feel a personal sense of safety, calm and glee, but they too are living within a context of cultural trauma.

78

Current Events and Political Reality The psychotherapy literature is only beginning to reflect responses to the most current events in the social and political realm experienced in the United States in response to the 2016 election and aftermath. Karen Hopenwasser (2017) wrote in an article for the Center for the Study of Affect Regulation’s website, In November 2016 something happened in the United States that has been experienced as traumatic by greater than 50% of the American population: the election of a president who embraces hate and uses shame as a tool for persuasion and control. What happens in psychotherapy when the sense of danger, when the helplessness and rage, are a chronic shared state, when the unanswered question is “how can this be happening? (para. 2) She continues by acknowledging, “Regardless of one’s personal views, we are all experiencing the collective trauma of fear and hate” (Hopenwasser, 2017, para. 2). It will be vital to revisit and address continuing literature on the responses, reflections and effects of current events as authors publish their experiences in of late. This literature has begun to be published and is further noted in the discussion chapter of this work.

Qualitative research, like this investigation, allowed the clinician’s experience to be understood with detail but, also in comparison to a small group.

Previous Research Research has considered how therapists work with political material but it is sparse and leaves room for further study (Avissar, 2009, Rosenwald & Hyde, 2006;

79 Samuels, 1993). Samuels (1993) conducted the first worldwide survey of analysts and therapists, asking open ended questions which were responded to via questionnaire. At the time, Samuels’ findings confirmed that politics, “is a welcome theme in a significant minority of clinical offices…clients are raising economic, environmental, and genderpolitical issues (including those that do not see the affect personally,)” but that the majority of respondents felt they lacked the training and literature to work with political material and feared it would be seen as “bad practice” (Samuels, 2004, p. 828). The outcomes of this study support the use of a qualitative research method to obtain detailed clinical data about the therapist’s experience.

Avissar (2009) was inspired by Samuels and conducted his own exploratory survey of Israeli psychologists; questioning the identification, occurrence, frequency of political issues, therapist response and therapist ideology, and training and personal activism. His research is specific to the politics and political issues for Israeli therapists.

The findings reflect a divide between more conservative theoretical ideas and the possible influence of Relational/Intersubjective theories which he suspects, “enable therapists to express attitudes, including political ones, more freely and openly, both in and outside of therapy” (Avissar, 2009, p. 188). In my discussion I expanded upon the themes Avissar (2009) touches upon in his research by adding the perspective of subjects working in the United States and by conducting in-person, semi-structured, open-ended interviews, offering more clinical details about the therapy relationship. Avissar (2009) does note that his subjects report high intensity political events as having the most impact on the life and well-being of clients and are most often the content of therapy.

80 Rosenwald and Hyde (2006) used a mixed method of research to explore the relationship between therapists’ political ideologies and the effect on practice in a survey of licensed social workers in the Mid-Atlantic U.S. Findings showed a belief that ideology was separate from practice, however, those who identified as more liberal more regularly expressed their ideology in practice than those who reported more conservative beliefs. How the social workers managed similar and differing ideologies was reported, but “overall, these findings suggest that political views were not incorporated in practice” (Rosenwald & Hyde, 2006, p. 15). Rosenwald & Hyde’s study is important because it highlights the need for training and literature to explore and consider the role of political ideology in context of clinical work. The researchers asked how the boundary between ideology and clinical work was maintained or blurred, but were not able to go into further depth around how political material, how the emergence of ideology is handled clinically, or its impact on treatment. Rosenwald & Hyde’s suggestions for further study include, “specific exploration into how political ideology’s manifestation in practice, for example through the use of practice vignettes, is warranted” (Rosenwald & Hyde, 2006, p. 20).

My work aspired to attend to this need.

81

Chapter III Methods The purpose of this research was to consider how therapists respond to, work with, and conceptualize political material that emerges in psychotherapy sessions. The qualitative study focused on the subjective experience of the therapist when politics presents in the therapeutic hour and how it is managed and responded to. What were the different ways “the political” comes up in practice? When the political did emerge in practice, how did therapists conceptualize and respond to it (explicitly and implicitly) and then how did they think about it outside of the therapy. How did therapists acknowledge and/or experience the impact of sharing an external political reality with clients? How did they manage self-disclosure in relation to these issues and has this changed over time?

The following chapter outlines the methods I used to complete this research including design, data collection and analysis, presentation of the findings and reliability, validity, and initial thoughts about limitations.

Methodology and Design This study used a qualitative design methodology based on Grounded Theory developed by Glaser and Strauss (1967). A methodology of Grounded Theory builds theory from the examination and interpretation of data, “in order to elicit meaning, gain understanding and develop empirical knowledge” (Corbin & Strauss, 2008, p. 1). The data was obtained for this study through semi-structured, in person, open ended

82 interviews in which the research participants, “explain and make sense out of their experiences and/or lives, both to the researcher and themselves” (Corbin & Strauss, 2008, p. 10). Qualitative research differs from quantitative approaches as it explains an event or circumstances but does not quantify it. Qualitative research does not seek to disprove or prove a hypothesis or use a pre-determined standardized set of questions in the inquiry.

This qualitative research attempted to understand of the breadth and depth of how subjective, personal, experiences are being handled, and develop awareness of some of the impacts, effects or challenges that occur because of such experiences. By using this methodology, the data offered a “thick description” of the phenomenon, revealing meanings and constructs (Geertz, 1973). This project was suited for a qualitative approach because it enabled the researcher and participants to explore therapist’s clinical experiences and reflections with politics and political material, a deeply subjective experience in itself. Corbin & Strauss (2008) explain it is vital for qualitative researchers to, “desire to step beyond the known and enter into the world of participants, to see the world from their perspective and in doing so make discoveries that will contribute to the development of empirical knowledge” (p. 16).

The data for this research was collected through semi-structured, open ended interviews with psychotherapists using an interview guide of topics to cover (See appendix I). Mishler (1986) describes interviewing as a process which is, “jointly constructed by interviewer and respondent” (p. 52). The data for this research was then examined utilizing a “constant comparative” method as described by Corbin & Strauss (2008) in which each subject’s response was interpreted, analyzed, and compared with an eye towards similarities and differences. As a result, categories were developed to

83 contextualize and develop themes in the material. Such analysis is described by Corbin & Strauss (2008) as, ‌interacting with data (analysis) using techniques such as asking questions about the data, making comparisons between the data, and so on, and in doing so, deriving concepts to stand for those data, then developing those concepts in terms of their properties and dimensions. A researcher can think of coding as “miningâ€? the data, digging beneath the surface to discover the hidden treasures contained within the data. (p. 66) This process of analysis began as soon as the first interview was conducted. In fact, future interview-guides were then adjusted to capture the responses of each subject most fully.

Participants and Sample The participants for this study were psychotherapists who work in private practice settings. I sought 5-7 subjects who provide therapy services and consider their approach reflective of psychodynamic psychotherapy. I found five licensed practitioners to participate. Their licenses included, Licensed Clinical Social Worker (LCSW), Psychologist (PhD or PsyD), and one participant was also trained as a Psychoanalyst.

Participants lived in a location that allowed me to physically meet with them, at their home office or business location, within an hour of travel from the Los Angeles Metro area.

84 This research elicited descriptions of subject’s interactions between themselves and their clients in psychodynamic psychotherapy. Qualitative research often uses small sample sizes purposefully selected (Patton, 1990).

The logic and power of purposeful sampling lies in selecting information-rich cases for study in depth. Information-rich cases are those from which one can learn a great deal about issues of central importance to the purpose of the research, thus the term purposeful sampling (Patton, 1990, p. 169).

I recruited therapists who wanted to discuss and consider their experiences with clients in a meaningful way. I did not limit my participants by age, race, ethnicity, or political ideology and while I hoped to obtain some variations between my participants, I did not control for these factors. The criteria for participation included a willingness to discuss specific case examples, personal experiences, and self-identification of their practice as psychodynamic.

I recruited my sample using a snowball sampling technique in which I asked a network of known colleagues and associations to refer potential participants who might have been appropriate for the study. “By asking a number of people who else to talk with, the snowball gets bigger and bigger as you accumulate new information-rich cases” (Patton, 1990, p. 176). I sent letters and/or emails to professional and personal contacts asking for referrals for my study (See Appendix A). I also posted online with professional groups such as the American Association of Psychoanalysis in Clinical Social Work, the Sanville Institute Alumni group, the California Society for Clinical Social Work, and the California Association of Marriage and Family Therapists (See Appendix B). I posted notices on Facebook groups I belong to including, Network of Professional Social

85 Workers, Mental Health Professionals, and Citizen Therapists for Democracy (See Appendix B). I had planned to advertise in newsletters for these professional groups as well, but it was unnecessary (See Appendix B). I asked for potential participants to contact me by phone or email initially.

I followed up with all potential participants with a letter, email (See Appendix C), or phone call in which I will described the nature of the study and participant expectations, risks and benefits and I used a brief questionnaire as a screening tool to determine if the prospective participant met the selection criteria (See Appendix D). Once participants were selected, I sent a thank you email to those who were interested but not chosen to participate (See Appendix E).

I scheduled in person interview appointments with the selected participants and sent them the Informed Consent document in advance of our interview (See Appendix F).

This form was reviewed and signed at the time of the in-person interview. Months after the interviews, the affiliation of my Institute changed, and I completed the process of reconsenting my participants under the auspices of the Institute for Clinical Social work and completed the Collaborative Institutional Training Initiative (CITI) certification. The informed consent included a review of my commitment to protect the anonymity of my participants and their clients. This pertains to the written dissertation as well as any future publication of the study. I refrained from using any identifying information or material that is distinctive or can be easily recognized. I kept all interview materials, including audio recordings, in a secure location and did erase audio recordings after the data has been transcribed and analyzed.

86 Participants were emailed the informed consent document prior to the interview and reviewed and signed a hard copy at the time of the interview. Researcher also verbally reviewed the benefits and risks to the study both in the initial phone call, as well as the in-person interview. Subjects were given the opportunity to ask questions and were informed throughout the study that they could stop the interview at any time. They were observed for any distress experienced during the interview, and researcher actively inquired about their reactions to the interview process and experience towards the end of the interview.

I conducted two pilot interviews before meeting with my subjects. This enabled me to consider whether the questions in my interview guide elicited the data and feedback I was attempting to elicit and allowed me to hone and revise my interview style and approach. This process helped me acclimate myself to the process of research interviewing and to obtain feedback about my approach from my pilot subjects.

Data Collection Data was collected for this study by audio taping and then transcribing the semistructured, open ended, in-person interviews between the researcher and subjects. An interview guide was used to help ensure that the researcher covered all the relevant topics (See Appendix I). The grounded theory approach allowed the researcher to use a combination of literature review and personal experience to develop the interview schedule, which provided the structure for the data collection. The interviews were between 60-90 minutes in length. Participants were encouraged to share openly and at length without being limited to specific questions or timing. Brief email contact was

87 made with the participants 6 months after the interviews in order to obtain re-consent form when the research transferred from the Sanville Institute to the auspices of the Institute for Clinical Social Work.

Mishler (1986) describes the interview “as a form of discourse� and as an interaction between subject and researcher (p. 7). The interview was shaped, not only by the questions asked, but also the many verbal and nonverbal interactions that occurred in the room between both parties. This type of interview allowed the subjects to answer in their own way and for their own meanings to emerge. Participants were aware ahead of time that I was looking to better understand their experiences with political material. I discussed with them prior to the interview my hope they would be willing to elaborate on their personal and professional experiences, including detailed vignettes and clinical examples. They were reminded of this intention at the start of the interview as well. At the interview, after reviewing informed consent and confidentiality procedures, I opened the discussion by encouraging the participant to speak openly and freely. The questions and prompts guided the conversation from general areas to topics that might be interesting to explore with more detail and depth. After each interview, made some immediate notes of my impressions, thoughts, feelings, observations and responses. I also listened to each interview and determined whether adjustments should be made prior or during the next interview. Data analysis began after the first interview and the research process was constantly evolving, as interview topics were added or changed to elicit and explore themes as they emerged (Corbin & Strauss, 1998).

88 Data Analysis This qualitative analysis did not depend on statistics, but used the constant comparative method for analyzing the data obtained from subject interviews (Corbin & Strauss, 2008). The constant comparative method is a systematic method for considering themes and patterns that emerge from the material collected by the interviews conducted.

“As the researcher moves along with analysis, each incident in the data is compared with other incidents for similarities and differences” (Corbin & Strauss, 2008, p. 73). The process of comparison continued until a point of saturation was reached and no new relevant information is produced. Theoretical comparisons included the process of grasping meaning for words or events that include abstract properties (Corbin & Strauss, 2008).

Corbin & Strauss (2008) explain that the coding strategies of axial coding and open coding work together. Axial coding is “the act of relating concepts/categories to each other” (Corbin & Strauss, p. 198). Open coding means “breaking apart and delineating concepts to stand for blocks of raw data” while simultaneously, “qualifying those concepts in terms of their properties and dimensions” (Corbin & Strauss, p. 198).

Through review of the transcripts and my notes, the data was first analyzed word by word. Emerging themes were noted and core categories were developed. Categories were then linked, refined and reviewed. This process occurred over and over and so that the essence of the subject’s experiences was captured in the development of the categories and sub-categories.

The notes I took immediately following each interview as well as tracking and noting my own responses to the process of data analysis helped me maintain awareness of

89 my own biases, reactions, and conceptualizations of the process. “Sensitivity stands in contrast to objectivity. It requires that a researcher put him –or herself into the research.

Sensitivity means having insight, being tuned in to, being able to pick up on relevant issues, events, and happenings in data. It means being able to present the view of participants and taking the role of the other through immersion in data” (Corbin & Strauss, 2008, p. 32).

In the fourth chapter of the dissertation the findings are presented. Here, I present data in categories and sub-categories that describe the themes, patterns, and variations that emerged along with samples from the data itself. Direct quotes and examples will support the findings. In the fifth and final chapter of the dissertation, I will discuss these findings, including an interpretation of my findings and the relationship to the existing literature, impact, significance, and limitations of the study.

Limitations and Validity Reliability and validity are concepts that are often associated with the evaluation of quantitative research. Reliability speaks to accuracy of the research and whether it could be replicated, while validity looks at the dependability of the research and if the study answers the questions it set out to explore. Corbin & Strauss (2008) note, Where the art comes in is in the ability to “make the scheme work” based on the data and the insight gained into the data.… The researcher must recognize when the scheme isn’t working…and when this happens be willing to take the scheme apart and rework it again and again until the analytic story all falls into place and “feels right.” (p. 274)

90 The constant comparative process offered some oversight towards reliability and validity in that the process included mining the same material multiple times, offering opportunities to add care and rigor to the process.

The limitations of this study included the inability to generalize the findings as the sample size was small. Once the sample population was determined and the data was collected, other limitations presented and are further discussed in the limitations section of chapter five. The external political climate impacted the findings in that the sociopolitical world is constantly changing but the interviews took place in only one moment in time. This research was limited by offering only a slice of experience contextualized to the time and place of the interview.

91

Chapter IV

Findings Review of the Methodology This research set out to explore and better understand the subjective experience of therapists in relation to the topic of politics and psychotherapy at a time in which external political events in the U.S. were particularly heightened. As described earlier in the methodology chapter, data was collected from five therapists, in open-ended, semistructured, in-person interviews with the researcher. The findings were grouped into four categories, with sub-categories and themes, defined and described below.

Participants The study involved interviews with five participants; one male and four females.

Participants’ identifying information is kept confidential, and so for the purposes of this writing each were given a pseudonym; Daniel, Alice, Natalie, Rosemary, and Helen.

Interviews took place in the office location for each subject’s private psychotherapy practice, two interviews took place in home office locations and three were in business office buildings across Southern California.

Four of the five participants hold a Master’s degree in Social Work. One of those four went on to receive a Psy.D and practices psychoanalysis. One participant holds a Ph.D. in social psychology. Each of the five participants defined their practice approach

92 as inclusive of psychodynamic psychotherapy. Three therapists also used the term, “relational� to describe aspects of their theoretical orientation. Natalie and Daniel were more expansive in their description of their approach, including use of evidence based practices, cognitive behavioral therapy, and somatic and/or attachment theories. These same two therapists had been practicing the shortest amount of time, both graduating with an MSW after 2006. These two also described psychotherapy as a second career, having worked as professionals in other fields. The remaining three of the therapists received their initial degree in the 1970s and early 1980s. The years of psychotherapy practice among all participants ranged from 11 to 42 years.

All five of the participants in the study were Caucasian. Daniel, Rosemary, and Helen identified themselves as Jewish, while the remaining two did not specify. Of note for this study, all five participants identify themselves as liberal and expressed discontent for the current Republican administration, including the President.

Overview of Findings After the in-person interviews were completed, the researcher took personal notes about reactions and responses to the interview. Each interview was transcribed. Using both the written transcriptions and audio recordings of the interviews, a process of constant comparison commenced, in which the researcher analyzed the data for themes and patterns that emerged across the interviews. In a manual process, the researcher compared the occurrence of each idea with other similar themes and responses within the data. Overlapping themes were compared to one another and consideration of the categories’ relationship to one another was refined until a saturation point occurred. Four

93 major categories, each with sub-categories, were revealed, capturing the essence of the subjects’ experiences and responses. They are: Finding I: The Personal Perspective Family of Origin and Development of Political Perspective Defining political Therapist’s political Self Social Work Values and Politics Finding II: Therapeutic Engagement in Special Circumstances Personal Responses to the Current Political Environment Heightened Political Events Are a Factor Recent Experiences Contrast with Prior Administrations Therapists Hear the Political Inner and Outer Differing Ideologies The Absence of the Political Finding III: Shared Reality Affect Regulation, Fear, and Safety In This Together Collective Trauma Recognition of a Shared Experience The Need for Caution Attitudes about Self-Disclosure and Neutrality Finding IV: Growth and Development Implicit Knowing and Closeness Spontaneity and Authenticity Explicitly Addressing Politics The Therapist’s Therapist Reflections of the Interview

Finding I: The Personal Perspective Family of origin and development of political perspectives.

This first category encompasses the participants’ personal subjectivities around what is considered political and their own relationship to politics. All participants referred

94 to growing up in a household that was connected to liberal leaning ideology. Daniel recalled, “everybody was Democrats that I knew of.” He went on to say, “I haven’t ever been exposed… I often feel, sort of naïve? I was raised in New York, LA, and I don’t know anybody who’s a Republican really. Vaguely” (Daniel, 2018).

Natalie and Alice described their family of origin’s political activity and values as impactful on them, but in different ways. Natalie explained, I was raised by activists… and that meant overtly with different groups and protests on Saturdays, and my dad is a union organizer, so there’s always this idea that your political lens shapes your work in terms of what is important…I think that example is really important politically. And so I hope that that’s what’s happening in my family, too, that yes there are overt conversations, but a lot of it is by example. (Natalie, 2018) Alice added that while her parents were very politically active, the effect this had on her left her struggling with what civic action means to her. She stated, That also left me with some conflict about what I wanted to do with myself in that arena.… Because I think that I had many, many friends who adopted themselves to my parents because my parents were really, they were liberal. My mother was picketing the draft board, and my parents had been socialist and that whole thing.

And so, there wasn’t a lot of space for me to really develop that identity for myself.… So for me it’s always been tinged kind of with what means something to me, and what does being active mean to me, and I think I tend to not be a very overt activist. (Alice, 2018)

95 Rosemary noted her family’s ideology, “I think that my parents were oriented toward a sense of community, and kindness…. There was just always some sense about people’s rights, and the treatment of people” (Rosemary, 2018). Helen also described growing up in a liberal family. However, she focused more on the impact that an important early relationship had on her responses to current political leaders. She stated, And everybody was Democrats that I knew of.… I think that this current man-I don’t even want to call him president—resonates personally with me not in a great way. My brother was a bully, not sophisticated like that.…I realized that, having that in my life, when I hear this guy (Trump) with this disgusting bullying, excuse me, but I could really get going.…(Helen, 2018)

Defining Political.

Each participant described what they consider to be political. While all five respondents identified the term political as inclusive of electoral politics, they also considered “the political” to include something broader, including gender and power relationships. Helen noted, “Politics is just, what is it, the physical embodiment of all these relationships, and the way governments operate because we have to have some way, some kind of frame or structure….” (Helen, 2018). Daniel and Natalie both used the phrase, “the personal is political” in their response. Daniel stated, “I think very concretely about what’s political. I guess talking about gender and is it the broader sense, everything’s political. The personal is political, right?” (Daniel, 2018).

96 Natalie explained, I have seven million answers going on right now. What is political? I think throughout my life I would have said everything is political, the personal is political. In terms of this lens, it’s almost like the definition changes by the person. (Natalie, 2018).

Like Natalie, Alice and Rosemary also noted how individualized the meaning of political can be and how the topic is part of therapy. Alice noted not only what she feels is “political” but, how she sees this in the psychotherapy hour, I think that’s probably how I would define political at this point. It’s really what comes up that feels bigger than the two-people sitting here and also specific to the person coming in to see me and that’s been really noticeable in the last few years.

(Alice, 2018).

Rosemary explained that issues of social justice, “informs a lot of my thinking.”

(Rosemary, 2018). Social movements such as, #MeToo, Black Lives Matter, issues of racism, and policy issues around violence, gun control and economic inequality were referenced by participants as political throughout the interviews. More than one participant brought up gun violence and school shootings as issues that they felt strongly about.

The therapist’s political self.

All five of the participants had some personal relationship to political activism, but the type and intensity of activity varied widely. Daniel’s participation began after the election,

97 I had been vague as a fan of podcasts and a reader of newspapers, and then, with the nomination of what’s his face became something that I actually wanted to get involved in. And so I started throwing a party. And then I created an organization… started doing voter registration trainings… participating in various events…I just had a call with a bunch of organizers… like, serious people…I have much stronger sort of voiced ideas about all this than I once did…this is what I consume in between sessions and it’s what I’m doing when I have some free time and I’m not working or being a family guy….My thinking tends to be “whoa, why isn’t everybody doing this? This is a movement.…That thought of answering to a future, What did do you do during those years? Is something I want to be able to do well….(Daniel, 2018).

All the participants expressed that the 2016 election elicited stronger feelings and reactions to the political for them, but the civic behavior in response to these feelings were unique for each participant. Helen described, I guess I’ve always been interested in politics, but never… when they would get combative, I’m not interested, I’m outta here…Let me know what the end result is, because it’s too upsetting… Things have changed so much with the current occupant so I have stronger feelings about politics…my husband and I were invited to join a group of people...a political group, and we have discussions…So our group ends up being a lot of venting, particularly since 2016…And every once in a while we talk about doing something. We did, several of us went to a fundraiser.... (Helen, 2018)

98 Rosemary, currently active in anti-gun legislation policy, described her political activity, I have never not voted. I would vote for anything. You’re going to get my riff here…. I think it’s a huge right and responsibility and blessing that we have here.

It peeves me when people don’t vote….The political process is important to me, not as important as for someone who devotes a great deal of her time to do it, but I’ve almost always done something politically, and would never not participate . …I don’t believe in giving away therapy.… I, like many people have been very upset about the shootings, the school shootings and all the shootings…. So that’s how I got involved.... It’s slow but it makes me feel like I can take an action.

(Rosemary, 2018) Natalie discussed her past activism as compared to her current activism, her desire to do more, and the limitations of time and family life.

So my boys are three and nine….They hear a lot of political conversations when my family and friends are over.… I have dragged him to several protests…. I have changed over time. What comes to mind is, I think before you're a parent, you have really strong ideals of like, "This is how I'm gonna raise my kid, and we're never gonna watch television." And then you have a kid and you're like, "I really have to take a shower." And that's, you know, so your political ideals are affected by the daily living. So yeah, my political expectations and my political involvement have changed over the years, and maybe in ways that I don't feel great about, but I'm also raising two kids and exhausted, so I don't have that

99 energy anyway, so it's a little self-compassion there. I would love to make space for that in my life.… (Natalie, 2018).

Alice expressed the most confusion about her political involvement by describing, “a feeling of really not being clear about what I need to do or contribute or not.… I really feel confused about that.” Alice went on to explain that some issues and types of participation are a better fit for her. She also noted that her activity is personal, often expressed though writing and reflection, “One of the ways that I feel like I can be active is my making use of the kind of awareness that I have as a psychotherapist and as a meditator” (Alice, 2018). Alice referred to a friend who goes to a meditation group and, “sits quietly for an hour… that’s his contribution to a more peaceful world right now… and I thought, Oh, I get that, that makes sense to me” (Alice, 2018).

Social work values and politics.

The data reflected the assumption of social work and psychotherapy as a leftleaning profession. All the participants made some connection between their choice of profession and the profession’s ethics, values, and socially conscious disposition.

Rosemary noted, “I’ve always been interested in what I call social justice. From the minute I heard about social work, I thought I want to be a social worker” (Rosemary, 2018). Natalie noted the challenge of working in private practice and her discomfort with the disparity of access and problems with the healthcare system and how this conflicts with the profession’s values. Alice also connected social work values to her own training and personal perspective, even though her degree is not in social work, “

100 …social settings, social, economic, political backdrop was really an important part of the curriculum… I think as therapists I really do believe that everything we do is value driven. I mean. So, to think that you can’t separate out at this point what’s going on in history of this country and the world (Alice, 2018).

Daniel articulated a belief that his training includes a social and political responsibility to his clients, As a social worker, there’s that sinless code of ethics that I’m supposed to be involved in advocating for change for our clients, and at the macro level…social worker's take on stuff is it's about systems. That training specifically addresses that question, which is, "You're having this problem inside a system, and the system is political, and maybe the solution is not to change yourself, but to change the system." That's built in to this training that I got. (Daniel, 2018)

Finding II: Therapeutic Engagement in A Special Circumstance The second category emerged from the participants’ descriptions of how major external events affect them, their clients, and psychotherapy. The data collected highlights how a heightened political milieu, as an example of an environmental experience outside of therapy, impacts individuals in explicit and implicit ways psychologically and biologically. All five participants expressed dismay at the 2016 election results and the subsequent political environment. Rosemary’s reaction encompassed the tone expressed by all five participants, “I think I’m just stunned… there’s no better way of putting it.… I was flabbergasted. I was speechless and I have to say, I still can’t believe he was elected”

101 (Rosemary, 2018). These circumstances were considered special by the participants because of the on-going chronic nature of the socio-political situation as Helen described, I don’t think any of us have experienced anything like this.…When are we going to get over this? …every single day some kind of scandal, or some kind of misdeed, or some kind of… disrespect. (Helen, 2018).

Daniel and Alice both highlighted aspects of fear. Alice explained, “It scares me that there’s not really a democratic process (Alice, 2018). And Daniel emphasized, Well, this seems like an all-out assault on everybody’s rights. As a Jew, some of this stuff is scary, has historical echoes, and now a big rise in voiced antiSemitism. There’s just no area that this administration isn’t touching that isn’t personally abhorrent to me.…(Daniel, 2018).

Three participants, Natalie, Daniel, and Alice, specifically noted that technology and the way they receive information impacted their experience of these circumstances.

Alice noted, “Not too long ago we weren’t getting a newsfeed every 15 seconds” (Alice, 2018). And Natalie stated, “I have alerts on my phone, which I need to turn off… sometimes I’ll see something… when I’m not in a mind-frame to… I don’t need that interruption” (Natalie, 2018). Daniel expanded upon Natalie’s comments about the impact of the constant newsfeed on his role, The number one job with your clients is to be present, right? If I’ve just read or I’m distracted by some piece of news or some unfinished email, or whatever it is, or some Tweet that I just read in my two-second breath between clients, that is challenging the basic primary responsibility. (Daniel, 2018)

102 Heightened political events are a factor.

Data collected around the participants’ recent experiences in psychotherapy highlight how politics emerged in 2016 in contrast to the past. The participants referred to current political events both personally and in their work as having a sense of “before and after” related to the 2016 U.S. election cycle and aftermath. All participants reported that the current political milieu came up in at least some of their therapy sessions with clients and that the frequency and intensity of the material was markedly different from before.

Daniel summarizes, Prior to 2016 elections or 2016 campaign. Yeah, everything was different… and that’s not just in therapy… That’s in life…The clients who are engaged politically are so worked up that they’re not boring (Daniel, 2018).

Recent experiences.

Alice described a, “level of devastation that people walked in with” after the election (Alice, 2018). Natalie recalls, “I remember one client asking, “Is everybody talking about politics in here this week?” and I said, “Yeah, yeah, everybody is. People are reeling” (Natalie, 2018). Natalie went on to explain, “I’ve talked about politics more since the election than ever before” Helen described some clients as, “depressed, rageful.” She explained, “I wouldn’t say everybody talks about it, but a good proportion…I just have people who are affected by the lack of civility, etc. in this current atmosphere” (Helen, 2018). This resonates with Alice’s statements, I mean with some people the conversation had come up already and you know the fear and what would happen…it just started to feel to me like these things would

103 come up more than I had ever remembered them. It just didn’t seem like, and I guess maybe it was also that things became more personal political. That that overlay was people started to talk that way more…my memory was this first couple weeks everybody brought it up… it was palpable in the room to me.

(Alice, 2018) Natalie also noted that the theme emerged for clients in new ways, Like I have this guy whose, I think he would have considered himself apolitical, worked in retail… And he went to the Women’s March. And he’s never been to a march before in his life… I have stories like that from different people.… More politically active, or more politically, even engaged in conversations than they previously were.…A lot of that. (Natalie, 2018) While Rosemary initially responded with “rarely” when asked if her clients talk about external environmental influences, she then continued to refer to distress clients shared around the election and politics. She stated, One is a very big circumstance, a very macro circumstance of people’s responses to the election of Trump. That came up, and then that I think it doesn’t necessarily have much to do with their own clinical piece, although I try and tease it out to see if there’s something about power, control…. Yes, people were very upset…

One of the people that I see is very, I’m going to say social justice conscious…

She talked about how wonderful it will be (if Clinton wins)… I saw her the following day, and she was beside herself. Now, she is a fairly dramatic person anyway, and a very labile person anyway.… (Rosemary, 2018)

104 Contrast with prior administrations.

All five participants noted that the way that politics came up in sessions during previous Presidential administrations was different. Natalie explained that talking about politics in therapy prior to 2016, “varied by client way more…But yeah, it’s much more common to be in the room now” (Natalie, 2018). Three participants recalled that the associations that came up in session around Obama’s election were different in nature than the current issues. Alice reminisced about Obama’s election, People had a feeling that something was changing in this country and moving and I think there was kind of a sense that you could feel that and people talked about that….I really do feel like I started to notice in my practice that people were bringing up things more directly about the political climate starting when Obama got elected…to have that sort of more of a blur between my personal belief system and what I was interested in, and the sort of mounting excitement that something different was really happening… to have that come up so vividly.… It just felt very unusual to me…the overlay of the clinical and what really seemed like almost like life threatening important, which was something I had not experienced before—like here was a presidential election that seemed like so much was weighing on it and I felt that. (Alice, 2018) Helen recalled, “Bush sort of elicited, because of the war… but not like this… with Obama it came up, and I can’t remember anymore why or how, but just that people appreciated him” (Helen, 2018). Daniel was succinct, “It’s more overtly political now than it had been during the Obama years” (Daniel, 2018). While Rosemary’s stated that politics “almost did not” come up prior to the recent election, she recollected, “People

105 certainly had strong feelings about Obama. I had a sense that that was much more interestingly enough racial than political. I’m not even sure I could tell you why” (Rosemary, 2018).

Therapists hear the political.

Inner and outer.

All five participants offered data that described their experiences listening to and making sense of their client’s outer external world responses while simultaneously staying mindful of the specific client’s inner psychic experiences and needs. The therapist’s conceptualizations of their clients’ highlight the individual nature in which each client is seen to metabolize and present material influenced by the real world. The participants hear these themes as individual in nature and in combination with what they know and understand about their client’s inner world. None of the therapists seemed comfortable attributing their client’s issues to only an inner process or an outer external situation. All acknowledged the combination of the two. For example, Natalie described her work with one client as inclusive of politics in terms of gender roles and identity, but also considered the dynamics her client experienced early in life.

Of another client she described, How do you separate his intrapsychic from the world he lives in? You don’t. You don’t, that’s ridiculous right? Yeah. And even my passionate 17-year old (client), when she’s fired up about politics, that’s also her exploring like, “What is my world? What is my role? Where am I in this?” That’s her intrapsychic stuff also

106 while we process the world…I think it has much more to do with her relationship with her parents.… (Natalie, 2018) Daniel offered multiple examples of listening to this material as both a real-life external situation and an intrapsychic issue. He worked with a few clients managing relationships with family who hold opposing beliefs. Daniel described his client as “able to walk in both these worlds where, as the country is torn” (Daniel, 2018).

Alice noted how she must toggle between listening and thinking about inner and outer psychic issues, …as time goes by you can see sort of people’s individual dynamics around the state of the world…I’m thinking of two people in particular… neither one of them have really found themselves yet.…“Like, oh now we have yet one more thing that we’re going to be angry about that isn’t going to work the way we wanted it to”….More of an internal piece…. Go back and forth. (Alice, 2018) Rosemary described how she listens for client’s patterns, I’ll just sit and be quiet because sometimes you just know…you need to listen, and wait, and listen and wait…it’s what informs beliefs…. I just am going to wait and see what they bring up. For example, with a fellow who said, “I think we ought to give Trump a chance. I really don’t like him but I think we ought to give him a chance.” This is going to come as no gigantic shock to you, but this is what he does in the rest of his life. He gives people way too many chances, and then he has walled himself off from any intimacy. (Rosemary, 2018) Rosemary seemed a bit more cautious than other participants to assign too much weight to the outside external environmental factors,

107 One of my colleagues has gone so far as to say that she thinks that she has seen more depression and anxiety in her practice since the election…. I'm not sure that I've seen more of that rather than I will be just projecting my own sense of lack of safety and security with this clearly pathological man. (Rosemary, 2018)

Differing ideologies.

Four of the five participants elaborated on their experiences working with clients who expressed differing political ideologies in detail. All the therapists expressed openness to working with clients who had a different world view although Daniel seemed to feel it would be highly unlikely given the ideology of the neighborhood of his practice.

“This core 40% and they’re not living (here)… not seeking out therapy from some middle aged Jewish guy” (Daniel, 2018). Rosemary was clear, “If somebody walked down here, and sat down, and said, “I love Trump. I think he’s wonderful and everything he’s done is wonderful” I don’t think I would say, “I can’t see you”” (Rosemary, 2018). However, the responses noted some differences in the way that therapists internally thought and responded when ideology was not aligned.

Natalie offered an example of work with a specific client, …Before the election, I had a woman who had post-partum depression, and she’s a woman of color, and she was totally pro-Trump, and she was writing a blog about her love of Trump.… And I summoned like, all my kind of compassion and presence and was like, “let me just be as clinically attuned as possible”… difficult for me… different than my viewpoint… she was bashing people… really kind of volatile…. I felt at the end of the session like, “I think I pulled it off”… then a

108 week later got a request for a provider change. And so maybe I wasn’t as connected to her as I was trying to be… she was really trying to have me say something pro-Trump, and I was trying to keep it as clinical as possible… she was like, “Aren’t you relieved he’s a voice of sanity? Don’t you think he’s a voice of sanity?” And I said, you know, “tell me what sanity means? Like I was just reflecting and reflecting. So that was interesting. (Natalie, 2018) Helen also experienced working with clients who have different beliefs, Couple of people say they voted for him and I’m like, (therapist goes blank)… and no response. I don’t say anything, I feel a calmness, I don’t think to myself “What the….” You know, I just feel like “Okay.…” It doesn’t change my opinion of them or anything….One said, “You, you’re my therapist, I can tell you anything I want. I voted for Trump.” And I just sat there. And she said, “And I can’t tell anybody. I can’t tell my friends.” .… And she just sort of had this burst and… I can remember because I was so startled by her… I kept that with me… but I never would say, “What the hell were you thinking?.”… The next week she came in and she felt sort of bad that she sort of let that out and I said, “why?”

Well, you know, she sort of regrets that she voted for him, but at the same time she thought this, that, and the other.… (Helen, 2018)

The absence of the political.

All the participants experienced working with individuals in the clinical setting who did not bring up politics or the election directly or explicitly. When clients do not acknowledge the external reality of the socio-political surround, it is still noted by the

109 therapist internally. Rosemary sums up, “…either people came in and talked about it and were distressed, and disturbed and upset because Trump had won the election… or they came in and didn’t say much about it at all” (Rosemary, 2018). All the participants made some reference to the inner world and unique circumstance of the client as a way of understanding the absence of the material connected to the external heightened environment. Daniel was the most vocal about how this leaves him feeling “taxed.” He explains, “I’m a little puzzled…that people feel disengaged and, they’re often, they’re disengaged from themselves and those are the most challenging clients anyway” (Daniel, 2018).

Rosemary reflected on her curiosity, “I just folded it into what I know about the person…a sense of them, and maybe just how the world is really their internal world mostly.…” (Rosemary, 2018). Natalie also included her conceptualization of why a client might distance herself from the topic, including those in her personal life.

It was like a distancing thing from her friends, that she was not caring about it as much as her peers… I get it… I get the impulse when it feels overwhelming. And for her… I think I thought more of a clinical concern about self-esteem and her social anxiety (Natalie, 2018).

Helen added, I would say that I just sort of think in my head, “Oh they’re not saying anything.”

And I don’t say anything…some people don’t read newspapers, or watch TVs… They’re not interested. It’s all too much for them, particularly based if they’re going through their own stuff, they don’t want more input…but if they don’t bring it up…I don’t think there’s a need for them to.…(Helen, 2018).

110 Alice shared, It wasn’t that they didn’t acknowledge something but I mean that they just didn’t spend a lot of time on it and some of that I think really has to do with whatever the degree of pain or struggle variant.…(Alice, 2018)

Finding III: Shared Reality The third category explores the acknowledgement by all five participants of the special circumstances of a shared external reality, including how this was experienced by participants in their professional roles, and the impact on therapy. The emergence of this category is illustrated by Alice’s statement, That I didn’t feel like I could say, “This is just your internal process, please let’s forget about what’s going on in the world”…that would have been crazy to me because I was feeling that way and the dance of how to express some of that honestly without feeling like I was just going to sit here and fall apart, which I wasn’t, but it was really something I paid attention to. (Alice, 2018) Her acknowledgment that she was simultaneously managing a response to the same external environment as her clients is at the heart of this finding.

Affect regulation, fear and safety.

Client reactions after the election were described by all five participants as inclusive of psychological and biological reactions and difficulty with affect regulation.

“People were terribly depressed. Crying, Depressed. It was pretty… stunned, everybody” (Helen, 2018). Helen and Natalie both referred to clients feeing physically ill. Helen

111 described, “One woman that I see came in saying that one of the reasons she was coming back into treatment…couldn’t watch TV, listen to the radio, read anything without feeling physically ill” (Helen, 2018).

Natalie stated, I have this mom who reads political things and gets really upset, and during the election she was telling me that she just has the shits, she was like, her digestive system was so messed up.…People were crying. The first month or two after the election, people were coming in here and crying and saying, “I don’t know where I live. I think I’m gonna move to Canada.” There was a lot of pain and shock.

(Natalie, 2018) Alice also described physical symptoms, “…we’re all pretty confused and things are changing at a much faster pace than they ever have and people aren’t processing, people aren’t sleeping as well….” Daniel’s summary also noted the impact on clarity of thought, “people are focused on the national nightmare, and…it’s stirring up a lot of anxiety for people.… Some people are really obsessed with it and come in really distraught and unable to think about other stuff” (Daniel, 2018).

In this together.

The data revealed that the therapists were not only listening to their clients respond but they, themselves, were also experiencing similar reactions, “And I say, “yeah, yes” (Daniel, 2018). Helen acknowledged that she has, “to watch myself when I’m in session” (Helen, 2018) and Daniel concurred that he was so activated, “… I have to be careful not to be too interested in that stuff” (Daniel, 2018).

112 Four of the five participants offered information around their own dysregulation and their efforts to notice, address, regulate or acknowledge their internal experience related to this content, in their professional capacity. This highlights that the affective experience of the participants was being mirrored by their client’s presentation, and the therapists’ intuitive need to regulate themselves and their clients.

Alice shared, …it felt to me like there was a real reason to be terrified. So, to pretend otherwise would have been dishonest…everybody has their own unique experience of things, but we all really are in this and I feel like that’s been much more a part of how I work, so that by the time all this happened it felt to me like, “well, this is just what we’re all in right now and yeah, it’s frightening and no, I don’t know what’s going to happen.”

She further explained what happened to her physiologically, I’m aware of what happens to me in those moments, where like I feel it like right here in my solar plexus.… A jolt like a panic… like fear settling in… I pay attention to that, but I mobilize pretty quickly out of it. (Alice, 2018) Natalie also refers to her internal state, So a couple of times with a couple of different clients…I’ve said like, “Let’s take a moment, and let’s breathe through this. And do we want go further, or do we wanna start deescalating? Do we want to switch tracks? What would be best for us to do now?... Let’s breathe, let’s figure this out. ” I most often get heightened politically…I have a 17 year old [client] so fired up and political and I have to keep us on track clinically. She’s like, “Did you read about this?” So we talk

113 about it and then… I’m gonna pull us back to what’s going on with you… she’s so good at sidetracking me into these conversations, and I do engage with them with her, cause it feels like really important rapport-building for us. (Natalie, 2018) Helen’s shared an experience she had with a client that also acknowledges a dysregulated state: I get into it with her.…Well, I start to get, what’s the word? When you’re filled with energy…I get heightened, very heightened, and then I will stop and say, Look, what’s this like for you? And she said, “I need to hear it…I’m trying to regulate myself.” She understands all that… I’m always left with a feeling that I wish when it comes up, I was more regulated. (Helen, 2018)

Collective trauma.

Each of the participants referred to their own and/or their client’s responses to the external political environment as akin to a trauma response. Helen succinctly stated, “I think we’re all traumatized.” Natalie recalled, “For many of my students, several…

Muslim…Latino, it felt like trauma to them. They were like, “Okay, we’re gonna be deported, or we are gonna be harassed in a way that is unprecedented” (Natalie, 2018).

Rosemary described the post-election experience, “I think for some people, I don’t think that the notion of catastrophe and trauma aren’t that far removed, because they see this president as so dangerous…I think it has been traumatizing” (Rosemary, 2018).

Three participants, Alice, Helen and Daniel expanded upon the idea of trauma and used the phrase “collective” to describe the phenomenon. Alice explained,

114 I mean it’s in the collective circle here of trauma. …it does feel sometimes like trauma is very individual and it is. The meaning of one thing to somebody is really different than somebody else but it does feel to me a little bit different than that right now. I feel like we’re in a collective trauma that registers to a greater or lesser degree at a given moment but it doesn’t feel quite so individual to me…

And that’s less really, I think, about who you voted for and much more about, how to we process all this that’s happening? (Alice, 2018).

Helen corroborated Alice’s sentiment, I think that the reality of what we’re going though is a group trauma, collective trauma, I think that we are all still shocked that this man could be president, what in the hell happened. I think there’s anxiety. I think it’s just in the air. Somebody told me they went to see their psychiatrist, couple of people told me this and they said something about anxiety and they said look in the waiting room. Everyone.

We’ve never had anything like this. (Helen, 2018) Daniel added, There’s a maybe, that sense of camaraderie that comes with all of us in the blue bubble here. All of us with this shared sense of horror.…And maybe into a situation that feels really different and new and is tied to some potential collective trauma or shared external reality that is tumultuous in a way that may feel different. (Daniel, 2018).

Daniel’s sentiments around a sense of camaraderie combined with Natalie’s comments, “Right after the election I think I was more self-disclosing, and that people were saying, “I really am so upset about it and I’m saying, I get it, like “me too” (Natalie, 2018), leads

115 to the next sub-category in which therapist acknowledges the shared experience amongst the therapeutic dyad.

Recognition of a shared experience.

Four participants (Alice, Helen, Daniel, and Natalie) highlighted that the recognition of a shared experience with clients occurred both explicitly and implicitly in the therapy. Alice summarized her experience in a manner that the other participants named above seemed to share, “I thought, “Well, hello, this is what’s happening right now.” That doesn’t mean they’re never going to talk about their internal workings. It just means this is what’s up and we’re all in it” (Alice, 2018).

These same four participants specifically highlight the therapists’ recognition of a shared experience both internally in the way they think about it but, also in their explicit acknowledgement with clients. Natalie stated, “And this is much more shared experience of like, What’s gonna happen next?” (Natalie, 2018). She also referenced a possible shift in boundaries in the therapy as a result: I think there was a shift in the boundary in that we are having a more shared experience when we talk about, when we reference those elements that it’s not, “it’s my life, I’m bringing to you”, it’s, “We’re in this together.” (Natalie, 2018).

Daniel also referenced how this sharing created a need for boundaries. “I have a client …we have to limit political talk to five minutes. It’s like “OK, five minutes I’ll do this” and it tends to bleed over. Cause it’s just somebody who he knows can have that conversation with him” (Daniel, 2018). The “knowing” that Daniel referred to is also referenced by Alice, Helen, and Natalie.

116 It’s nothing new but we’re finally acknowledging…to have that out in the open is a shared reality that in some ways is really validating…I think what has happened is people have said, “oh my god, I was just reading the news, and it’s so upsetting” and I will say, Yeah, yeah, I hear that [nodding vigorously and looking distressed]…so I’m showing the emotional experience. (Natalie, 2018) Alice also talked about assumptions made about the therapist’s experience. Of one client she shared that she, “Just makes kind of an assumption that we were both on the Women’s March together…it’s almost like an unspoken thing that we both have…it feels like a commonality in the relational space to me” (Alice, 2018).

Four of the five of the respondents referenced that the client must broach the topic first in session. Daniel’s response differed somewhat from the others. He said, “And then others don't bring it up but I tend to check with people about whether ... If they report increased distress in some other area, whether the national mood isn't getting on them to some extent” (Daniel, 2018). Once it was brought up, four participants highlighted that their responses to clients included honesty and acknowledgment of the shared nature of the impact on both client and therapist. For example, Natalie’s client asked her, “Are you getting the shits too?” She reported responding with, “No, but it’s totally affecting me physically, I get it” (Natalie, 2018).

The need for caution.

All five participants noted the need for caution related to shared experience, the political milieu, and the exposure of the therapist’s position in treatment. Alice wondered if the discussion might offer, “something in it for me too” (Alice, 2018). She continued,

117 “I mean, maybe it came up at other times but not with sort of regularity or where I felt a push and pull within myself to really talk more honestly… to engage or not yeah….”

(Alice, 2018). Helen corroborated this reflection, What I have to watch is that I get energized, and I do talk with them about what’s going on and I’ll even ring in, “did you read this or that?” And I have various reactions. All of them are appreciative. If I ask them, “Look, I’m saying all these things, what’s that like for you?” “Well, I’m glad to know it. I thought so.”… Not because I had said anything before. I didn’t introduce it before they did”…. And somebody will say, “Oh I'm so relieved that you think the same way (Helen, 2018).

Attitudes about self-disclosure and neutrality.

The interview revealed the participants attitudes and feelings about self-disclosure and neutrality. In general, all the participants seemed to share an attitude in which thoughtful self-disclosure can be clinically useful, but must be used with care.

Helen explained, “I grew up in training, you didn’t disclose yourself…. But then…it’s not like you don’t. It’s considered. It’s thoughtful…. I grew up in that you don’t, leaving the person the space to imagine” (Helen, 2018).

While Natalie articulated her view on disclosure, I have acknowledged, not so much self-disclosure but really kind of validating...I do a lot of self-disclosure in like, how I’m feeling right now, like, “I’m feeling really tight in my chest what’s happening with us right now.” And I welcome that,

118 because that feels like attunement, as opposed to, “this reminds me of the time when I.…” (Natalie, 2018).

Like Natalie, Alice seemed to feel there is a way to use oneself as a therapist, People don’t understand self-disclosure in kind of a general sense. I think that for me I don’t disclose a lot about myself personally but I’m very personable, so if I do disclose a lot about myself personally, (it’s) without giving my whole life freaking story. (Alice, 2018) Daniel added that with more professional experience, he has developed a stronger sense of how and when to utilize self-disclosure.

I still carry the textbook notion that self-disclosure should serve the clinical effort and not be about relieving the therapist’s need to be heard. That just seems like good therapy. I think, as I have more therapy hours under my belt, I have a better sense of when it’s okay and even welcome, to join with somebody. (Daniel, 2018).

Like Daniel, Alice highlighted that her responses and disclosures are individualized.

“There are a lot of therapists who think if they disclose a lot of personal stuff that they’re actually more in relation to somebody. Not so, as far as I can see. I think it’s just gratuitous” (Alice, 2018).

Rosemary was the most traditional in her reply, With questions that I don't know what to do with them quite yet or I'm simply bloody not going to answer it, I will say something like, "I want to know more." I will be very shrinky with that. I will say, "I will get around answering that, but I want to know more”…because I will give it right back to them. “This is your

119 therapy, not mine." If they get mad, then that's even more stuff to talk about….That's right. If it's not useful or necessary, I'm going to probably not do it.

If there's an elephant in the room, we will figure it out. (Rosemary, 2018)

Finding IV: Growth and Development The fourth category unpacks further the impacts and effects that a heightened external environment has on psychotherapy relationship and the therapist’s growth from the perspective of the therapist. Overall, it seems that the participants’ response to a collective trauma included increased authenticity, spontaneity and enhanced use-of-self in session with clients. This resulted in the experiences of enhanced intimacy and closeness in the therapy and growth and development on the part of the therapist-participant.

Implicit knowing and closeness.

The participants acknowledged that some of their clinical experiences included an aspect of feeling known by the client in ways that were implicit. Four participants supported a theme of enhanced closeness with their descriptions of what occurred between themselves and clients, “commonality in the relational space” (Alice), “a closeness with more attunement” (Natalie), “familiarity, even if it’s not discussed” (Helen), and “a nice joining and breaking down of the artificial barrier” (Daniel).

Alice further elucidated, It feels like a way of like, it reminds me of like the way people feel close to their therapists sometimes…it has to do with the color they wear or where they go on vacation. It feels like in that real of things it makes us more human or when

120 there’s some tragedy somewhere that everybody has a response to…And I don’t think leveling the playing field some other time is a bad thing. I think it’s really important… I feel like we are really always looking for a relational connection, so why should we be depriving each other of that.… It also feels to me almost like a way of connecting to me like, you are with this right now and they’re not saying that. (Alice, 2018) Daniel also highlighted that knowing something of one’s therapist might be useful for some. Here, he was referring to his clients’ learning about Daniel’s own political participation, There’s a good rapport if people have been coming here for years. It’s not, “Oh I didn’t know you were a person in the world.”…My sense of it is that it’s easier to know that your therapist is involved in a macro sense than to think of your therapist as having kids. And it’s competition for that parental affection. Maybe even, where there’s this parental figure gone bad. The president. Maybe, at some level, you want the substitute parent therapist person to be going to bat for everybody in that way. (Daniel, 2018) Natalie added, We are sharing this reality in a more explicit way… I think it has been through those small comments of like, “Oh I heard about that, it’s so upsetting” and when I kind of nod with empathy, then they take that as the spring board.… But if they’re as attuned to me as I’m trying to be to them, maybe they are sensing the subtle shifts and the openness to those conversations. I feel like I’ve had a couple clients who said, “You didn’t vote for Trump, I’m sure.” And then looked at me,

121 and then I didn’t say much, and so they were like, assumed that I was…there’s a shared kind of political understanding about the nature of gender.”

(Natalie, 2018).

Helen also acknowledged her clients know something of her and that this may be tied to the way she presents herself in session, They started maybe talking about it. And probably something I said or didn’t say… there’s a familiarity even if it’s not discussed, sort of a way of being in the world, I think. And so, I think people probably assume I think it’s a way of being in the world. Maybe sensitivity to the world, a sensitivity that they feel. There must be something about how I am (Helen, 2018).

While Rosemary offered statements that do correspond with the other participants’ responses here, “I cannot believe that they didn’t know how I stood,” she also stated, “My sense of it is that they would still not necessarily implicitly know where I stood on the election.” (Rosemary, 2018). Rosemary also described some assumed association between her profession and a left-leaning ideology. “I think that people experience me as not judgmental and not critical. I think then there is the association of a stereotype of, “She must be a more liberal left leaning person” (Rosemary, 2018). This was an experience the other participants also shared. Daniel described, “I think there’s an assumption in this neighborhood…in a blue profession, that there’s a Democrat and an anti-Trump person sitting across….” (Daniel, 2018). Natalie concurred, A huge part of the therapeutic process is self-compassion and understanding… all the kindness we can give ourselves.… And that does not feel like the rhetoric of the right. It’s maybe just by nature of this work, they know I’m not blaming,

122 judging, and naming. So maybe they assume. I wonder how many people assume that a therapist is left-wing or whatever? (Natalie, 2018)

Spontaneity and authenticity.

Participants described how recent events and interactions in therapy required them to use greater flexibility and creativity within the therapeutic relationship in the form of spontaneity, authenticity, and genuineness. They are not hiding their own feelings as much when they agree and there is a sense of commonality and commiserating that occurs as a result. Natalie described this as an, “intentional loosening.” She described, I was working with this older black man who had fought in Vietnam… he said, “All these black boys being shot, it’s fucking me up.” And I said, “Me too.”…I didn’t wanna take away his experience, but like for me it was just a really genuine reaction, like yes…I think it was just after another shooting. That was hard. For me to have reflected and been like, what’s that like for you? Would have felt shitty? (Natalie, 2018).

Helen described how these new external circumstances have impacted her responsiveness with clients, “…I think it was somewhat spontaneous, and I think as I listen…. I think there’s some kind of real emotional content to it.…” (Helen, 2018). She notes the positive response clients have had to her genuineness and commiserating, as well ways she has changed and grown as a therapist. She describes some clients as, “Oh I’m so relieved that you think the same way”…and maybe this whole political thing has sped it up a little bit and so I feel looser, more comfortable, more—“Oh my God I just said that.” Because I grew up you’re not supposed to

123 say much. I find myself lately really acknowledging their courage, it brings tears to my eyes. I think I’m finding myself more and more attending to, and pointing out, the courage to even think about being different. I think I’m commiserating and I think they appreciate it. I wish that I could not commiserate but the genie’s out of the bottle and it’s hard. Prior to this, my commiserating was probably more internal. I think it is a bonding experience, and I think that they feel like they can talk about it. (Helen, 2018) Natalie shared, “…there is something really freeing about letting the boundaries be looser. And that does feel kind of like a political act sometimes. Like, above all, we’re human. We’re humans who have a relationship” (Natalie, 2018).

Alice added, I was thinking that maybe one thing that I’ve noticed a little bit different about myself in these couple of years when things come up that are more in the political range is that I think I actually I’m a bit more spontaneous than I typically am about responding. Like so if somebody comes in and says, “Did you hear about blah blah blah?” I don’t pause much on it, I’ll say, “Yeah.” (Alice, 2018).

Rosemary’s response was not reflected in this sub-category. She said, “I would not let that even creep out in the consultation room,” about sharing in or commiserating with clients (Rosemary, 2018).

124 Explicitly addressing politics.

Three participants described feelings about bringing politics into the room in a more intentional explicit manner. Of all the participants, Daniel seems the most forward in his approach with clients, I don’t think I know how everybody’s voted, of all my clients that I’ve ever seen.

But, I think I assess for it gently. I make recommendations. Oh, you might want to sign up for such and such newsletter if you’re looking into canvassing. That’s case management, right? I have some resources that might be valuable to this client and so, as a social worker, I share them. (Daniel, 2018).

Rosemary shared a different perspective on this theme, Is there a place to bring up politics in the session when the person has not broached it? No, but I do think it’s a very interesting idea. I’m pretty much not going to bring up anything in a therapy session that I haven’t… I am curious as to whether there are therapists who actually do in their history taking. Do you have guns in your home? That’s not asked by most people. I’m going to pursue that…

If I can figure out…when is it appropriate to ask about are you politically active?

Now, that might be an interesting thing.… (Rosemary, 2018).

Alice was very wary of having an agenda, I’m thinking about someone I’ve known, she’s a person who actively brings political issues into therapy sessions and I don’t know exactly how she does that all the time…if you didn’t address every political or ethical or other issues, it was almost like you were failing the world in some way and I found it so annoying….

125 It felt angry… too pushy… too much… and she’s psychodynamically oriented… too much her agenda… so to me, it’s still the client’s session. (Alice, 2018).

The therapist’s therapist.

Four participants noted that they have had their own therapy at some point and shared vignettes or experiences that came from their own therapy, in which they were the clients. Natalie’s shared an experience in which she met with a couple’s therapist who disclosed with her that he had been up the night before watching the testimony of female U.S. gymnasts confronting their abuser on trial, And he was like, “And it was just really hard, but it’s really compelling, but it’s hard to turn off” and I was like, as a client, it was wonderful, and very humanizing. But like, he’s watching this, can’t turn it off, really affected emotionally by it. I think he said, “My wife was like, turn that off, its bothering you and I was like, I can’t!” And I was like, Yes! Shared experiences! That was cool. It was very effective. It was inviting” (Natalie, 2018).

Daniel explained, Yeah, I too have sleepless nights. And I know, as a client in therapy, that it’s been meaningful to be joined with that way. Like, this mental health professional, who’s not supposed to be crazy, knows what I’m talking about maybe I’m not so crazy. And then it’s normalizing.… (Daniel, 2018) Along these lines, Daniel explained that his own public participation in the “resistance” has resulted in some reflection about how clients might respond to knowing more about his personal civic-self and determined that this is a, “risk that I was willing to take, that I

126 can have a life in the world in a way that didn’t feel open to me fresh out of school” (Daniel, 2018).

Rosemary’s example was shared with the interviewer during the in-person interview but, after the recorder was turned off and so no transcript of the exchange exists. She shared that she had spoken to her own therapist about her concerns and response to the political environment, and found her own therapist was quite responsive to her. She reported that it is possible that since she is a therapist herself, her therapist had looser boundaries, but that despite the reason she found the experience positive. She described feeling bonded to the therapist and that it was helpful to her to know that she and her therapist held some shared feelings about the election and politics.

Reflections of the interview.

All five participants corroborated a positive experience of the interview process.

The consensus was that the interview required the participants to think about these topics in a new way. Primarily the participants expressed gratitude for the space to hear themselves reflect upon their recent experiences and make some meaning of what has occurred lately. Rosemary described the interview process as, “Fun, because I had to think about some things that I had not thought about. Also, nobody has really talked about this. It’s brought up some questions for me” (Rosemary, 2018).

Helen was positive, as well as thoughtful, of what was brought up for her. She and Daniel both acknowledged some awkward feelings. Helen reflected, I mean, it's just very thought provoking, your questions are thought provoking, like there's space to think about it, and at first I thought, “Oh God, I don't know.” I

127 felt a little shame in there, which is not ... Probably the commiserating has a piece of shame in it. (Helen, 2018).

Daniel acknowledged, “I talk this much in therapy and nowhere else. It's always a little bit strange to just talk. Some self-consciousness about that. About sounding selfinterested. That's something scary” (Daniel, 2018).

Alice concluded, I said to you on the phone that it wasn’t like something that I had spent a lot of time consciously thinking about, but the minute we were talking…Well, we’re in the midst of right now and so I feel like it was really helpful in me thinking through kind of how it’s been in the last 18 months….But you never know, but it does bring things up. It does because it’s a different territory a lot of this stuff.

Much of the time and even less so in the world we live in now (Alice, 2018).

128

Chapter V Discussion This chapter discusses of the findings from interviews conducted with five therapists. Below, the therapist’s experience is discussed with consideration of the initial intention of the inquiry in combination with the theory and literature presented in earlier chapters of this work. Interpretations and conclusions are discussed, including an assessment of the limitations, implications for further study, and the relevance and contributions to the profession.

Overview of Study This study explored therapists’ personal and professional experiences and clinical exchanges regarding “politics” in psychotherapy. The overarching research question considered how therapists respond to, work with, and conceptualize political material that emerges in psychotherapy sessions. The data offered the opportunity to develop insight around the meaning and impact of personal and clinical interactions surrounding the political in and out of psychotherapy from the perspective of therapists. Participants’ experiences elucidate some of the sub-questions considered in the study including, how, when and under what circumstances “the political” emerges in psychotherapy, how therapists understand their role, manage regulation and disclosure in the context of a shared heightened external political reality and, how therapists respond and think about

129 these issues and their impact on therapists and psychotherapy. The qualitative data highlights the challenges of managing collective trauma within the treatment relationship and finds that heightened external circumstances do impact psychotherapy and the therapist and that through a process of inquiry and self-reflection therapists experience enhanced growth and development.

Introduction Recently, events in the socio-political environment have emerged in psychotherapy with increasing frequency and intensity. The abundance of literature since the 2016 election is evidence that therapists across the county feel this shift as unusual, and warrants deeper consideration. Since the initial literature review for this research was conducted, many lay and technical publications have included articles about the therapists’ experience, response, consideration of the political and its impact on clients, practice and therapy (Benjamin, 2017, Brenner, 2017, Coren, 2018, Farber, 2018, Orbach, 2018, Petrucelli, 2017, Stozier, 2017, Raskin, 2018, Rozmarin, 2017a, 2017b, Yourman, 2018). These additional sources and perspectives are primarily written by individual therapists and their separate, distinct voices illustrate the need for additional research to better understand aspects of the impact of the socio-political that extend beyond one singular voice. Qualitative research, such as this work, can consider emerging themes across multiple experiences, noting similarities and differences and offering a depth of understanding beyond a singular point of view.

The therapist-participant’s personal perspective is the point of view for this dissertation; five reflections of individual meaning and clinical experience were

130 compared and analyzed. Findings were organized into categories that encompass more than one therapist’s outlook. Overall, this research found that therapists’ relationship to their worldview is shaped by their early family experiences but, that civic engagement exists on a continuum. The individual’s reactions and responses to collective trauma and heightened socio-political scenarios outside of therapy penetrate the co-created, special therapeutic space. The intensity of a shared reality challenged therapists to enhance their sensitivity, creativity, authenticity and responsiveness with certain clients, while simultaneously remaining astute to their own regulation. These interventions led to increased closeness and feelings of greater intimacy in the treatment relationship. In this study, the therapist-participants grew and developed in response to the challenge of a heightened socio-political world, using the research interview as a forum to reflect upon their experiences and development.

A Note about Historical Context Theory is developed in the historical context of its time and a social constructionist perspective endeavors to understand development and social phenomenon within the circumstances in which it was developed. Similar concepts should be applied to this research. Context has been a determinant in the development of psychoanalytic theory from the very beginning. For example, Freud’s aggressive drive theory and the death instinct were developed in the aftermath of World War I; shaped by a time in which over 16 million people lost their lives. (Gay, 1989, p. 394, Bendicsen, Koch, and Palombo, 2010, p. 9). Freud continued to refine his theories in the context of growing fascism and the rise of Nazism and anti-Semitism in Europe. His later work, Civilizations

131 and Its Discontents (1930), is seen as a recognition by Freud of man seen in the context of his culture (Freud, Riviere, & Stratchey, 1963). Just as the study of Freud, or any theorist, should not be untaken without consideration of the backdrop of the social, political, historical and environmental frame in which it was developed, research needs to be framed similarly. While this research study is tied to the time in which it was conducted, it should also be considered in a larger sense to understand change and growth in the profession. Psychotherapy theories and practice must continue to be updated as they move through time and history with responsiveness to the ongoing trajectory of history and human experience. We always must consider the impact of history as well as current events and consider implications on our evolving practice. Incorporating the expanding base of knowledge and science about the body, brain, and mind on the practice, process and theories of psychotherapy allow practitioners to grow and develop with the times.

This work is a living document. The context, social and political circumstances and cultural milieu surrounding the material are dynamic and ever-changing. Therefore, a note about the environment during which this research was conceived and conducted is warranted to ground it in time, and place. The initial stages of exploration for the research commenced in the fall of 2016, a time in which politics in America had rapidly become a chronic, amplified, hostile, environment on display 24 hours-a-day, like a never ending serial drama with real life impacts and dire consequences. Development of the first three chapters occurred throughout 2017, interviews in early 2018 and the dissertation was completed in 2019. My interest in studying the therapist’s interaction with socio-political material was certainly motivated by my personal experiences as a psychotherapist in the

132 months leading up to and including the November 2016 U.S. election. As the intensity and frequency of the material emerged with my own clients, I felt challenged to consider and reflect on my own growth and responsiveness and I wondered about other therapist’s experiences. The week after the election I began to collect and read articles and research around the concept of shared trauma to help make sense and inform my own practice, as I felt I was navigating new territory personally and clinically. This is not the first, or last time, activating social, political, or environmental events in the world have been noted in psychotherapy literature. However, as each step of the research process was completed, it became clear that the current external socio-political climate was becoming a persistent, intense, unceasing, chronic atmosphere of acrimonious perspectives. Safety and security feels at risk for many. This, combined with technology that encourages 24/hour access to real-time events in new ways, increases the challenge of learning new ways to monitor, metabolize and manage our responses to the outside world. Our use of technology allows us to follow and be open to exposure, at times intrusively, to incidents that may be physically distant but feel close.

In the time since the introductory chapters of the project were conceived, there have been incidences of gun violence in places of worship, schools, concerts and bars, withdrawal from key climate change accords and nuclear arms treaties, a highly contentious supreme court justice confirmation hearing, questions about Russia’s role in the electoral process, heightened mid-term elections, and the longest government shutdown in history. The President has embraced the use of term “nationalism,” declared a state of emergency on the Southern border, supported efforts to detain and separate migrant children from their parents and has been critiqued for his disdain for the truth and

133 his attacks on journalism. Research participants were interviewed one time only in April and May 2018 but, the ensuing discussion of the findings takes place within a backdrop of chronic, contentious and chaotic socio-political circumstances that continued to occur after the interviews. It is within the context of this backdrop that this research was conceived, developed and completed and by the time this dissertation is shared, additional history will have been added to the background as we hurdle forward in time.

Bias This study is not free from bias and assumption by the author. I was, and continue to be, personally upset and dysregulated by events in the country and around the world.

My decision to commit to research on this topic was driven, in part, by my desire to participate in the political landscape in some way. Every participant in my study shared similar feelings about the current events. Because of this commonality, I wonder if had some predisposition to assign meaning to responses because of my bias, or make assumptions about respondents and their answers. Did my shared ideology with participants create a sense of over identification that could have limited further inquiry or impeded me from really hearing something because I was too closely aligned? While I am aware of the possibility that I missed themes or did not probe in areas another researcher would have because the personal subjectivity I bring to the table.

Personal Perspective and Participation Descriptions of the term “political� by participants corresponded with definitions in the literature (Avissar, 2016, Cushman, 1995, Samuels, 1992). It is valuable to

134 understand that the participants feel that “politics” as a concept involves more than electoral politics and includes issues of policy, power, authority, human rights, gender and race dynamics, and economics. This more inclusive description is the foundation upon which the participants responded to questions in the interview. It is important because it signals that political material in psychotherapy does not only allude to electoral politics as Alice described, “It’s really what comes up that feels bigger than the two-people sitting here and also specific to the person coming in to see me.” Natalie and Daniel used the term, “the personal is political” to exemplify their statements that, “everything is political.” While their usage strays from the origins and intention of the phrase as a feminist slogan (Hanish, 2009) it does align with Hill and Ballou’s (1998) description of the term “the personal is political” to acknowledge sociocultural and structural influences on the psychological.

During the interviews, participants shared details about their own political perspective, the development of their political-self and relationship to activism, social work values and definitions of “political” as a concept. Botticelli (2004) notes, “Whatever form our activity takes outside the consulting room, it is bound to affect our theory and practice as relational therapists” (p. 649). In general, the organization of the findings in Chapter 4 moves from the personal experience of the therapist to their professional role and then back to their personal and professional growth. This speaks to the personal nature of the interview experience and alerts one to the inability to divorce a therapist’s personal relationship to the political fully from their work as a therapist.

Participants referenced the values of social justice, equality and human rights as part of their choice to pursue social work and psychology professionally. Considering how one’s

135 professional choices intersects with their civic mindedness or personal beliefs goes beyond the scope of this project. However, one might speculate there could have been political action and ideology in the choice of the participants’ profession.

Therapist self-reflection is a necessary component in a psychodynamic therapy process. Andrew Samuels, suggests, “We need to balance our attempts to understand the secret politics of the inner world of emotional, personal and family experiences with attempts to reveal the secret psychology of pressing outer world matters such as leadership, the economy, environmentalism, and nationalism” (Samuels, 2001, p. 1).

Developing insight around the relationship between the inner world and outer issues is important, and the participants used the interview process in part to reflect upon the connection between their own inner world and recent outside experiences. During the interview, each participant shared some details about their individual “civic” style.

Civic Style Each participant revealed strong, negative responses to recent events in politics.

The lack of diversity in ideology is a limitation, but also useful as a homogenous factor in the constant comparison of the data. All respondents referenced a liberal philosophy in their family of origin and I think this influenced their current stance. Natalie, Alice, and Rosemary each made some reference to a relationship between the political principles in their homes and their own value of civic participation. While some of the participants’ civic engagement and activity was influenced by their family of origin, activism and participation in political activity, seems to exist on a separate continuum. For example,

136 Daniel only developed his current highly active participation style recently, in response to the election, and made no connection between this and his family of origin.

Motivation and ability to participate in politics or civic action is complicated, nuanced and influenced by multiple factors. One might be enraged at a specific policy but cannot or will not participate in the efforts to change the policy. Alice holds strong political opinions and ideas, but she is unsure what form her own activism should take and thus questions the best way for her to “participate.” She explained that her own parent’s highly active political involvement left her feeling as if, “there wasn’t a lot of space for me to really develop that identity for myself…” noting, “I tend not be a very overt activist.” Samuels (2004) notion of the “Inner Politician” asserts there are various ways to “do” politics, offering a list evoking images of different political types. “…A spectrum ranging from active styles to passive ones: warrior, terrorist, exhibitionist, leader, activist, parent, follower, child, martyr, victim, trickster, healer, analyst, negotiator, bridge-builder, diplomat, philosopher, mystic, ostrich” (Samuels, 2015, p. 81) The data revealed examples of diversity in civic style including leader, activist, philosopher, parent, diplomat and healer. Alice is quieter in her approach to civic participation, exemplifying the stance of the healer or philosopher. Alice described a friend who joined a weekly meditation group, explaining that sitting silently is his contribution to a more peaceful world. Alice remarks, “Oh, I get that, that makes sense to me…One of the ways that I feel like I can be active is my making use of the kind of awareness that I have as a psychotherapist and as a mediator.”

Therapists constantly balance a personal and professional role that requires attention to the amount and type of personal information they reveal. There are

137 disagreements in the literature around the necessity of therapist neutrality, and the possible impacts of making personal political views public on an apolitical stance in therapy. The recent heightened atmosphere, combined with social media and the increase in personal information accessible in the public domain, may impact the way therapists evaluate the risks of their personal activism becoming public. Daniel’s recent civic style is a leader, activist, and parent. The election of 2016 impacted him so intensely that he adjusted his life to spend time organizing, working and participating in what he describes as, “the resistance.” He explains, “…this is what I consume between sessions and it’s what I’m doing when I have some free time…” Daniel has thought about how to manage being seen by clients as having a stance outside of therapy, but it did not deter him from his activities. How might Daniel’s strong stance affect his work with clients who are not as civic minded as himself? He shared a challenging interaction when a client used her session to discuss her feelings about an aspect of the “resistance” that Daniel was involved in as ineffective. Daniel recalled having difficulty managing his internal response and expressed some discomfort when retelling it to the researcher. He reflected that he may not have handled it with as much “grace” as he intended but, it is an example of how the current events challenged his development and growth.

Natalie feels the demands of parenting and management of work and family limit her political activity, “…maybe in ways that I don’t feel great about.” However, even in this limited activist capacity, she described attendance at rallies, discussion with friends and participation in pro bono intakes for asylum seekers as ways she currently participates. Helen discussed feeling limited in her own participation in part due to personal struggles with engagement with conflict. Early family experiences with a

138 difficult brother leaves her feeling that that when discussion of politics becomes controversial or heated, “I’m not interested, I’m outta here.” She has found ways to channel her participation by combining it with social events and book groups. Rosemary holds a firm belief that therapeutic services should not be offered free of charge and so she searched for a civic activity that fit her world view, ultimately finding anti-gun violence legislation. The diversity of the participants’ engagement in the political process and activism highlights that that there are multiple avenues to development of the civicminded-self. While exposure to liberal views and ideology early on may contribute to political leanings, as one grows up it may or may not account the type and style of activism. It is of note that therapists, with the exception of Daniel, did not share much about their own inquiry into their client’s development of civic and participatory style in psychotherapy sessions nor did they seem to think about it too much outside of therapy.

While the topic of civic action came up in therapy sessions (in the context of going to marches, voting, etc.), there was less discussion than the researcher expected of how therapists assess for and work with the development of a “civic-self” in their interpersonal therapeutic work with clients. This omission may have been due to the lack of engaging questions in this vein but, might also speak to an area of clinical discussion either seen as taboo or undervalued as part of a psychodynamic treatment.

Therapeutic Engagement in Special Circumstances “National trauma” and “cultural trauma” are terms that apply to the recent events in the socio-political landscape (Neal, 1998, Alexander, Eyerman, Geisen, Smelser, & Sztompka, 2004). Every individual in society does not have to feel events as terrifying

139 personally for these concepts to be valid. The nature of this circumstance is on-going so, it seems as if there is always some new report of disquieting news or action. If one group is experiencing a trauma, it exists in the zeitgeist of the time, and we are all interacting with it. In Southern California, where this research took place, the overarching feeling in the communities that the therapist-participants work and live, there is a predominate feeling of collective or national trauma. Heightened environmental circumstances do make their way into therapy and the current socio-political events were no exception.

This is not surprising and was expected. It fit with the personal experience that influenced my interest in this topic and the experience being shared informally among colleagues before, during and after the 2016 election.

Since the time in which the research interviews were conducted, literature has been published describing the impact of current events including psychotherapists’ personal reactions to the election, the social environment, and client responses. This literature utilizes very similar language as the participants in this research, reiterating the feelings and reactions expressed in the data here. (Slavin, 2017; Wilson, 2017; Gurlanik, 2016, 2017a, 2017b; Spielberg, 2017; Harris, 2017a, 2017b; Rosenfield, 2017; Sandberg, 2017; Khouri, 2017; Farber, 2018; Benjamin, 2017; Petrucelli, 2017; Rozmarin, 2017a, 2017b). The editors of Psychoanalytic Dialogues (2017) note that individuals are “… troubled and bewildered in the present moment, as citizens, therapists, and patients” (Bass, Ipp, and Seligman, 2017, p. 354). The introduction to a special “political issue” of Contemporary Psychoanalysis dedicated to the election and aftermath describes, Trump’s election feels to many of us like being sinisterly transported into the pages of a dystopian novel, where every normative notion we hold about

140 rationality, progress, and fundamental decency is upended and shattered: We are living in an exigent and tumultuous time (Petrucelli, 2017, p. 448).

These articles and personal reflections from therapists confirm what the data showed; that indeed, this is a heightened circumstance, one that challenged therapists and clients personally, leaving them feeling overwhelmed, distraught, and noticing that this feels different.

“It’s Much More Common to Be in the Room Now” Participants reported that they and their clients shared many similar psychological and physiological reactions to the election and aftermath. The therapists used words to describe their responses including, “humiliated, stunned, speechless, traumatized, fear, frightening, chronic, assault, inundated and scary.” The personal stress reported by the therapists interviewed was mirrored in their description of the stress reported to them by many of their own clients. The descriptions of their clients in therapy match the descriptions they used for themselves, including, “devastation, anxious, reeling, distressed, depressed, rageful, fear.” Natalie noted, “People are reeling.” Every participant reported that the election, politics and socio-political issues have presented in therapy sessions, even though not every individual client expressed dismay or discussed these topics in an overt manner. Some clients do not allude to these topics explicitly at all, but all five participants experienced an increase in the frequency that this material presented in therapy.

The way we take in and metabolize news and events seems related to a higher level of distress. And it is important to note the distinction in the way we obtain

141 information, news and shared material. Chronic alerts and regularly updated social media feeds impact the therapist’s mood and concentration as they enter sessions with clients.

Natalie explains, “…I’ll see something when I’m not in a mind-frame to. I don’t need that interruption.” Daniel’s stated, “If I’ve just read or I’m distracted by some piece of news or some unfinished email in my two second breath between clients, that is challenging the basic primary responsibility.” Daniel means his responsibility to be present and attuned to his clients. This underscores the individual and personal effect the outside world has on therapists, impacting their contributions to the intersubjective space.

They were going through something emotional, psychological and of deep concern to them personally and that cannot be switched off necessarily when sitting in the therapist’s chair. Their clients were also entering the psychotherapy space with the same exposure to the same alerts. Each member of the dyad was potentially metabolizing and processing external triggers which affect mood, safety and regulation internally as sessions began.

It is no wonder that clients were bringing this up more often. For many it may have been the material at the top of their minds. Client material and responses often mirrored the therapists internal experience. In his introduction to the 2018 issue of the Journal of Clinical Psychology, Barry Farber writes, “Trump’s election as president of the United States seems to have generated more in-session psychotherapeutic discussions than any political issue since 9/11” (p. 714). There was a powerful need to talk about these things in therapy with increasing frequently and intensity in the last few years.

While some aspects of the social and political had come up in therapy previously generally, “…It’s much more common to be in the room now,” explained Natalie.

142 Although this was not the first or only time politics as a theme has entered the therapeutic space, differences in the quality and quantity of what “came up” were noted.

Helen, Alice and Natalie notes that with Obama, while it came up occasionally, the quality of feeling was more positive. For Alice the time of Obama’s election was, “more of a blur between my personal belief system and what I was interested in, and the sort of mounting excitement at something different was really happening. It just felt very unusual to me.” This is noteworthy because it highlights an example of a shared experience which challenges the therapist to acknowledge something different and develop and grow in response. While individuals are always impacted by their social, political and cultural surroundings, it seems that recent ongoing events have led to a sense of “before-Trump” and “after-Trump” which demarks the in-session experiences in a different way. Daniel statement summarizes a sensibility that seemed shared by other participants and reinforced by the recent literature, “It’s more overtly political now.”

Rosemary also shared personal and client responses to politics, but she did so with much more ambivalence, and occasionally conflicting statements. She was more reluctant to directly admit the frequency and depth that politics explicitly came up in therapy, though her actual statements confirm that indeed it did emerge with her clients.

She explained that the political came up in, “… circumstance of people’s reaction to the election of Trump…Since he was elected for sure, and probably right before the election…” But, in the same hour-long interview she also stated, “We didn't really talk very much about it.” Her ambivalence is discussed further in this chapter as it relates to the use of self-disclosure and shared experience.

143 “Intrapsychic Stuff Also While We Process this World” While Rosemary’s narrative offered an example of the unique and individualized way that therapists listen and understand socio-political material presented in therapy.

Rosemary was quicker than other participants to attribute political material to something about the client’s individual psychological make up. She describes one client’s need to talk about her distress over election as, “Now she is a fairly dramatic person anyway, and a very labile person anyway.…” There was a minimizing quality to her need to assign the client’s distress to her labile emotional style which seemed tied to her discomfort with how to discuss politics, or how to express to the researcher that she had indeed discussed politics, a fact that may have elicited discomfort. She expressed concern that conceptualizing her clients issues as related to the reality of external environment might be a misinterpretation or a denial of the inner needs of the client. She seemed the most concerned of all the participants that veering away from the internal world of the client was somehow inappropriate or outside the bounds of the psychotherapy.

Primarily, material is brought forth by the clients without provocation by the therapist in a psychodynamic based psychotherapy. The participants heard political material and themes individually and thought about them in relation to what they already knew about their clients social, environmental, and inner worlds. Nunberg, Dahl, Herschkowitz, et al. (2011) noted that shared events warrant a review of theoretical conceptualizations that consider the collective reality and its interaction with intrapsychic life. The data represents illustrations that therapists do consider these interactions. The participants understood that the relationship their clients have with the external social and political situation was not mutually exclusive from that client’s own history,

144 relationships, and inner world. When discussing clinical work, none of the participants attributed client material or conceptualizations exclusively as part of an “inner” or “outer” realm. In fact, the importance of acknowledging the reality of the external to better understand their clients’ internal world was highlighted.

A relational theoretical perspective understands real, imagined, internal and external experiences all as central to the development of the self (DeYoung, 2015, Aron, 1996a). Intrapsychic and interpersonal influences are complimentary and one cannot be uncoupled from the other (Mitchell, 1993). Natalie simplifies, “How do you separate his intrapsychic form the world he lives in? You don’t… that’s ridiculous, right?” Of a specific client, she describes the therapy as attending to “her intrapsychic stuff also while we process this world.” The therapist-participants were cognizant of a need to, “…allow one’s relationship to social reality, rather than interpreting it as a displacement of a symbolic reference to unconscious conflicts.…” (Redding, 2008, p. 318). Alice offers a similar sense of indignation around the idea that she has to choose to understand her clients only one way, “I didn’t feel like I could say, “This is just your internal process, please let’s forget about what’s going on in the world”… that would have been crazy….”

A relational approach does fit with the participants attitude this circumstance. Rozmarin (2017b) writes, “We need to recognize that our unconscious is subjective, intersubjective and collective, that our sense of the world and ourselves is generated in our parents’ arms, but also on the streets of this and far away countries, and in how the media covers or doesn’t cover what happens in them” (p. 467). Generally, this captures what the therapistparticipants attempted to accomplish when they were thinking about their clients. The added on-going and constant nature of the social and political world likely means that

145 therapists must constantly re-calibrate their thinking about these “inner” and “outer” interactions for each client.

Altman (2006) suggested in a roundtable discussion, that a sociocultural unconscious may be part of the organization of individuals (Layton, Hollander, & Gutwill, 2006). Alice explained that recently, “you can see sort of people’s individual dynamics around the state of the world.” In fact, as time progressed Alice describes some of the anger at the outside world expressed by a couple of her clients as, “more of an internal piece.” By this it seems that she means the unique way in which the inner and the outer world interact and create this individual’s subjective emotional experience. Alice described how some of her young-adult clients, who expressed fear and anger after the election, seem to use this disgruntled stance to function as a confirmation that the world is difficult for them. While Alice was also angry at the state of the world, she differentiated between the origins of her client’s anger and her own. This ability to manage differentiation highlights the proficiency of the therapist-participants. They were adept at listening for and hearing many things simultaneously. Thinking about clients in this way, and responding to them with this insight in mind, is clinically useful and may result in opportunities for better attunement and authenticity in the clinical relationship.

The absence of the political.

In general, the lack of political material emerging in therapy was attributed mainly to the client’s needs. Natalie saw some clients as needing distance from politics and Helen agreed, “It’s all too much for them… if they’re going through their own stuff, they don’t want more input.” Alice also agrees, “I think really it has to do with whatever the

146 degree of pain or struggle.” Generally, it seems that despite the heightened political reality and possibly even shared ideology, some clients needed to use their therapy time to focus on other issues and this was understood and respected.

Daniel seemed more “puzzled” by the absence of the political than the other participants. Daniel is also the most explicitly politically active and seemed to have the least amount of political diversity in his practice. Political action and participation is how he spends all his free time. Daniel is also the only participant who revealed that he might introduce the topic with a client who does not bring it up themselves. Based on his intuition and observations, he might ask a client experiencing some distress in their lives, “Do you think there’s come connection between this thing going on now? Cause there’s so much. People are feeling harassed or feeling any number of things.” In response to this inquiry Daniel reports that, “There’s nobody who says, “What are you talking about? I don’t watch the news.” Daniel’s perspective is that everyone is being affected by what is going on, that no one is immune to its reach. This researcher initially had a strong reaction to these statements and wondered if this was an example of some over identification with his clients, or a projection or need for Daniel. But upon further thought, this could offer an interesting line of inquiry and might offer added opportunities for client growth and insight. Like all clinical interventions, attention to timing and purposeful, thoughtful approaches often yield growth. Contemplation of this type of intervention, considering the way in which the current atmosphere has touched so many, may be valuable to consider.

147 Working with differences.

All the participants, except Alice, detailed some experience working with clients with opposing social policy or political beliefs. The overwhelming homogeneity of political views between participants and their clients limits the discussion of differences.

However, some important issues and themes did emerge. Working with clients who share differing beliefs required therapists to pay close attention to how and what the participants share explicitly in session and to manage and monitor their responses differently than when views are shared. “… I would never say, “What the hell were you thinking,” Helen explains. Avissar (2016) writes, “The most difficult situations are those in which there is a gap or even a clash between client’s and therapist’s views, or between personal therapy objectives and the collective interest, as the therapist sees it.” (p. 98) Therapists responded differently to material and affect that are in opposition to the therapist’s personal views than with clients whose views fit more with the therapist’s beliefs. Participants had to modify their responses and this exemplified how therapists accessed their capacity for empathy and utilize their “use of self” in their work. Working with differences offers a good example of how therapists stretch and grow to meet the needs of the clients and bring awareness to the individual process needed for that client. It is another example of how they used their conceptualizations of a client’s intrapsychic life to understand them. Of a pro-life, Libertarian client Daniels explains, “It fit with him in a way. He made sense.” Psychotherapy is not a cookie cutter endeavor.

Rosemary shared the most experience, both personal and professional, of being with people who disagreed with her perspective. She spoke about dear personal friends who “are lovely people” but also, “bigoted” Trump fans. She explained, “These are

148 people that I care about very much and I think they're wonderful, and I thought, "What is wrong with you?" Rosemary certainly felt she was capable and successful working with those who did not agree with her politics.

Notably, there were efforts made by most of the participants to keep their internal responses and reactions muted in session when ideologies were not aligned. This aspect is not only interesting, but ties into the later discussion around shared ideology in which an increase in sharing and commonality around the shared reality is related to stronger therapeutic intimacy. With differences though, there is almost a cutting-off of the natural and emotional responses with clients, an attempt to keep the therapist’s differing world view internal. Rosemary states, “My internal…he’s talking about keeping guns like I make sure that I have enough fertilizer…that’s it.” When she states’ “that’s it,” it feels as if she is cutting off her interpretation and her response internally to the material. She adds, “he doesn’t know anything about my view.” There is a sense of distance and staying hidden that is different from responses to those who shared in the external reality with similar feelings. Helen also tried to stay neutral. “Couple of people say they voted for him and I’m like—[Helen makes a flat, neutral, blank fact]—and no response. I don’t say anything, I feel a calmness. It doesn’t change my opinion of them or anything. I just think, okay.” This need to “go blank” is important to understanding that clients who have differing beliefs have access to different explicit responses from their therapists. The therapists “did” something to manage the distance that opposing views might create and make attempts to stay connected to their clients. This internal and explicit action is different than the responses therapists had with clients who hold shared beliefs and opinions.

149 What is the impact of this lack of openness, spontaneity and authenticity on the treatment relationship? Natalie described an experience which was not as effective as she had hoped. She met with a client who was, “totally pro-Trump” and described her effort to maintain neutrality, I summoned like, all my kind of compassion and presence and was like, “let me just be as clinically attuned as possible… difficult for me… different than my viewpoint… I felt at the end of the session like, “I think I pulled it off.” Then a week later I got a request for a provider change. And so maybe I wasn’t as connected to her as I was trying to be.

Natalie’s experience was an initial session, and so cannot be considered in the same way as working with a long-term client, but it is still informative, nonetheless. Like Natalie, none of the participants offered examples of challenging or discussing explicitly an opposing ideological stance with clients. Solomonov and Barber’s (2018) research confirms that the experience of participatory discussion of political material by therapists occurred more often when ideology was shared than when it was divergent. Working with differences did not alter the therapists’ attempt to use themselves to deepen a therapeutic relationship and understand their clients. The capacity for sitting with clients who might touch upon dysregulating material is part of a therapist’s job. The interviews exemplified how differences between the clinical dyad may require a therapist to self-monitor internally and to modify responses based on the individual client with flexibility and control, despite internal reactions.

150 Shared Traumatic Reality and Collective Experience The phenomenon of sharing in the reality of a collective trauma outside of psychotherapy precipitated change and growth in the therapists. The pull of the need to commiserate and join with clients, when feelings were shared, initiated authentic and neurobiological responses in session, creating moments of spontaneity and creativity and deepening a sense of connection and intimacy within the dyad, resulting in growth for the therapist. All five participants used the term trauma/traumatic as part of the description of their own and their clients’ experiences of the world outside of psychotherapy lately. As noted in the literature review, “shared trauma”, “shared traumatic reality” and “shared reality” are used to describe the collective experiences of exposure by both therapist and client to trauma and shared heighted experiences (Baum, 2010, 2012, 2014; Baum & Dekel, 2010; Benyakar, Baruch, Kretsch & Roth, 1997; Bauwens, Glassman & Tosone, 2014; Keinan-Kon, 1998; Tosone, 2011; Nuttman-Schwartz, Stephens, & Tosone, 2012).

However, this literature is limited in its direct application here since it is primarily based on experiences that are tied to the consequences of man-made situations of physical jeopardy (i.e. terror attacks and living in war zones) and natural disasters (i.e. hurricanes) and does not encompass a contentious, dramatic, chronic, and heightened external sociopolitical landscape. Alice’s description helps to elucidate how therapists experienced this: I feel like we’re in a collective trauma that registers to a greater or lesser degree at a given moment but it doesn’t feel quite so individual to me….isn’t just people coming in their own experience of personal trauma….that’s also what lends itself more to self-disclosure because it feels like it’s bigger than everybody.

151 One effect of sharing this traumatic reality was more explicit recognition that social and environmental factors have always influenced the relational space. Philipson’s 2018 article notes that the election left therapists and clients experiencing “clinical symmetry as co-participants” (p. 3). The current heightened situation seems to have “outed” this more directly. Natalie explains, “This is nothing new, but we're finally acknowledging. And so to have that out in the open is a shared reality that in some ways is really validating.” The experience of things being more “out in the open” leads the discussion to note the implications of a “collective” or “shared” experience, finding that therapists had to bring awareness to their self-state in an effort to remain attuned to their clients’ needs.

“We’re in This Together” As Benjamin (2006) explains, “…We’re all human, and we fall apart in the face of hatred and aggression or too much pain, or we dissociate, or we become unable to really think in these situations” (Layton, Hollander, & Gutwill, 2006, p. 172). This reference is from 2006, but in 2019 it is just as relevant to current circumstances. At the heart of psychotherapy is a human relationship and when one, or both, of those in relation are in pain, scared, overwhelmed it will move into the therapeutic space. Typically, a therapist uses their professional wisdom, experience and training to manage their own experience in ways that meet the needs of the treatment at hand, however, here we must explore the impact of scenarios in which the existential and real threats challenging individuals is shared, chronic, and on-going. The participants were troubled and distressed and many of their clients were as well. The following discussion considers this

152 shared disturbance in personal regulation when its origins are tied, in part, to a shared external reality experienced by both client and therapist. Regulation and neurobiological theories add depth to our potential to understand political material in psychotherapy sessions, particularly considering the intrusive nature of news and social media. How therapists managed disclosure in this circumstance, the effects and clinical consequences of therapist choices, and behavior is discussed.

Affect Regulation Therapists and clients experienced a host of psychological and biological reactions before, during and after the 2016 election resulting in dysregulation and disorganization. The therapist-participants described their own and their client’s experiences as, crying, depressed, stunned, physically ill, the shits, agitated, worried, people aren’t processing, aren’t sleeping, a national nightmare, pain, shock, murderous feelings, obsessed, and distraught. If regulated affect is a key to functioning well, and if reports of dysregulated affect increase after politically charged moments in time, then the connection between how we metabolize socio-political material and its impact on affect regulation is relevant to this exploration.

Hill’s (2015) assertion that, “the regulation of affect is fundamental to the organization of bodymind and thus for adaptive functioning and subjective experience,” is valuable to this discussion (Hill, 2015, pp. 27-28). Findings indicated that the relational encounter in psychotherapy for some dyads was impacted by a change in regulatory function on a neurobiological level. This impacts the implicit right-brain to right-brain interactive and reciprocal process between client and therapist, contributing

153 to the experience of the intersubjective space that is created only between those individuals for that moment. Schore and Schore (2008), highlight that intersubjective work is about “how” to be with a client, and that the work of therapy includes being with clients amid “affectively stressful moments” (p. 17). The data here, offers some insight into the therapist’s process and accommodation for being with clients whose regulatory systems are compromised, while simultaneously managing their own dysregulation and affective challenges in relation to similar external stimuli.

Four of the five participants offered some reflection and insight about the psychological and physiological circumstance that this unique situation created. Alice exemplifies this process when she explains why she could not only attribute her client’s terror to an internal process. “…I was feeling that way and the dance of how to express some of that honestly without feeling like I was just going to sit here and fall apart, which I wasn’t, but it was really something I paid attention to.” Helen, also acknowledged a heightened sense of attention, “I have to watch myself when I’m in session.” Alice’s use of the phrase “the dance” is useful here to exemplify the experience of the participants. They were trying to manage multiple emotional states within themselves while remaining receptive, grounded, regulated and available for their clients. While this process is likely not unique and is part of the day to day experience for psychotherapists, the heighted socio-political milieu, the chronic nature of stressful event after event, the existential strain on the collective, and the 24-hour news cycle and constant bombardment of media created a new and significant outlying experience for these psychotherapists. The awareness that the therapist brought to the situation feels

154 different from other moments in which there may be some counter-transference or projective identification.

It becomes imperative to recognize that external events puncture the safety of the therapeutic space in multiple ways, including the regulatory system and adaptive functioning for both client and therapist. Helen exemplifies when she explains what happened internally when this came up in session, “I got into it with her… I start to get… when you are filled with energy…I get heightened, very heightened… I’m always left with a feeling that I wish when it comes up, I was more regulated.” Natalie also used the word “heightened” to describe herself session when this material emerges. She described how she must be mindful about “keeping us on track clinically.” This ties into the strength of the desire and need to talk about the current socio-political milieu. Her use of the pronoun “us” is a reference to sharing in something together with her clients.

Therapists are not immune to the power of the pull to share in the commonality of the collective experience. And, the participants all expressed some thoughtfulness and effort to restrain their own internal desire to talk about politics unless it was clinically indicated by the client in the session. Daniel expressed this as, “I have to be careful not to be too interested in that stuff.” The therapists’ in this study were attuned to the impact of heightened events and assessed and acknowledged the varying arousal states and lack of safety their clients felt. Natalie offers examples of how she was tracking her client’s arousal levels and monitoring them moment to moment, “Let’s take a moment, let’s breathe through this. And do we want to go further, or do we wanna start de-escalating?

Do we want to switch tracks?” She thoughtful about her intervention by strategically

155 offering opportunities for her clients to regulate their affect with her, enhancing their safety and security.

Safety and trust are integral components of a well-functioning nervous system and the individual’s nervous system is regulated in the context of relations with others (Porges, 2017). The participants and many of their clients were, as Daniel notes, “focused on the national nightmare.” Philipson (2018) writes that recent experiences may leave both participants in the dyad susceptible to “a powerful sense of foreboding and insecurity about the future” (p. 3). This sense of worry, fear, agitation, and terror can impact a sense of safety for both parties. Dysregulation by both therapist and client may create another potential risk of over identification amongst the dyad, which could lead to the therapist missing out on opportunities to meet the client’s specific individualized needs and would impact safety as well. Safety can be a key component of relational encounters in psychotherapy that allow for implicit and explicit communications and regulation. Bromberg’s (2011) explanation that the “dual role of the analyst as psychobiological regulator and co-participant, and that this duality is especially vital during heightened affective moments” is particularly poignant. Alice’s described her nervous system arousal in session. It seems that she uses a process of auto-and selfregulation to manage these feelings in session. “I feel it right here in my solar plexus…A jolt of panic, like fear settling in. I pay attention to that, but I mobilize pretty quickly out of it.” She did not look to her clients to regulate her, but expressed a sense of responsibility for offering her clients engagement with a safe, regulated individual. To this point, Daniel adds, “even in total chaos, the basic principle of, be the less anxious person in the room, is valuable.” The data here falls short of answering how client’s

156 perceived safety was impacted by the therapist’s activation and dysregulation over shared material.

Shared Reality Creates Opportunities for Growth Participants acknowledged that the heightened nature of the environment led to increased exposure of their perspective with clients resulting in a need for caution around the exposure and management of their own feelings, attention to the dysregulation of clients, and impacts of the external on the treatment relationship and therapy. Recognition and acknowledgement of dyad’s implicit and explicit participation and experience of being together, speaks to the relational nature of therapy (Atwood & Stolorow, 1993; Mitchell & Harris, 2004; Benjamin, 1998). Managing the impacts of a shared traumatic reality within the context of the psychotherapy relationship resulted in growth and development for the therapists. The implicit and explicit divulgence of the therapist’s stance required creativity, reflectiveness and flexibility as they had to manage an increase in their own spontaneity and authenticity in session.

Self-Disclosure Natalie states, “Right after the election I think I was more self-disclosing.”

Literature addressing shared traumatic reality suggests that in times like these, disclosure is kind of a “moot point” and the data reveals this to be true primarily when a sense of shared perspective existed in the dyad (Nutmann-Schwartz, Stephens, and Tosone, 2012, p. 233). Recently published research, which looked at the effect of the political climate on patient experiences with self-disclosure in psychotherapy fits with the findings here

157 (Solomonov and Barber, 2018). A majority of the 604 psychotherapy clients sampled by Solomonov and Barber (2018) reported that therapists did disclose their political stance, explicitly and implicitly around the time of the election, during treatment. Solomonov and Barber’s work highlights that discussion of politics in session may lead to a stronger therapeutic alliance, linking a connection between shared political views and strength of therapeutic alliance. This fits with the experience shared by most of the therapistparticipants in this qualitative study, this researchers own personal experience, and is consistent with Rosenwald and Hyde’s 2006 study in which they determined that social workers with more liberal political ideologies claimed to use their ideology more in practice than more conservative counterparts. Solomonov and Barber (2018) also suggest that clients have desire to discuss these topics and may benefit from such disclosures and discussion.

Two therapist-participants in this study referenced the disclosure of reactions to social and political issues by their own therapists in their own psychotherapy. Both expressed a positive experience with this from the perspective of a client, one explained that if felt like a “joining” opportunity, leaving them feeling closer and more aligned with their therapist. As I shared with colleagues, friends and family the topic of this research investigation, I have been offered multiple examples of stories in which clients were appreciative and grateful that their therapists offered a human and genuine personal response to their dysregulation around the world at large. One friend wrote to me in a personal communication about her return to therapy after the election, “I appreciate that a trained professional has expressed her shared trauma around the election of Donald

158 Trump with me, as opposed to just asking me how I feel. Our sessions have helped me to realize that I’m not alone.…” (Busby, 2018, personal communication).

Disclosing shared dysregulation around heightened events enhances positive experiences in the therapeutic relationship. Positive effects of disclosure, in general, can include intimacy, validation, insight, differentiation of self, authenticity and relief (Farber, 2006). From the perspective of therapists, disclosure around their feelings enhanced a reciprocal sense of intimacy and attunement with clients. We cannot use this data to confirm how the clients felt, but clearly the therapists’ perception was that clients felt a similar closeness and attunement in these circumstances. Feelings of validation, authenticity and even relief by the therapists after political disclosures were noted. In line with research and literature on the topic, the disclosures and discussion, occurred primarily when ideology was agreed upon and the nature of sharing was not necessarily about the details of one’s political views or ideology but disclosures around the affective responses to the external environment, described by the therapist-participants as “commiserating” together.

Caution with disclosure.

The need for caution regarding self-disclosure in these circumstances was reiterated by participants. They highlighted an emphasis on the individuation of treatment, and thus disclosures, based on nuanced conceptualizations of client’s needs.

Therapists were not engaging in fully open discussions as they would with friends over dinner. Application of meaning to political disclosures was individualized, since each treatment relationship is unique. Farber (2018) notes, “…while they continue to keep the

159 clinical focus of sessions on the client, they have also allowed their political convictions and beliefs to be known to many of their clients to a far greater extent than other parts of their personal world.” (p. 715) The caution around disclosure expressed by the participants, echo’s concerns about how self-disclosure might be misused and misunderstood in a relational therapy leading to unnecessary disclosures, potential devaluation or exclusion of the focus on the individual as an effect of over identifications (Aron, 2005; Bernstein, 1999; Samuels, 2015).

Rosemary expressed concern that to describe her clients as having more depression or anxiety related to the election might would be, “just projecting my own sense of lack of safety and security with this clearly pathological man.” Not only did she not want to reveal her perspective, she was less inclined than the other participants to acknowledge the shared nature of the current reality in general. Rosemary’s perspective might be accounted for by some anxiety around exploring formerly taboo social themes that have previously been “unlinked” from the psychological by theory and practice (Layton, 2006). Layton (2006) herself describes some anxiety in a clinical interaction, “…I found myself struggling throughout the session against the urge to close off this inquiry with an interpretation that would reduce what she was saying to the kind of psychological insight that separates the psychic from the social” (p. 110). Rosemary’s concern about her own possible projections may also highlight her care not to over identify with them. When similarities are recognized within the therapeutic dyad, the risk of over-identification increases, jeopardizing that the therapist might miss opportunities to support the needs of the clients, in the service of an over identification (Kantrovitz, 1996). Kantrovitz (1996) explains that the consequences of this over identification is

160 collusion in which conflicts, individual issues and problems are not recognized and examined. “This failure to explore and expand the areas in which patent and analyst are similar impedes the growth for both parties.” (Kantrovitz, 1996, p. 108). Impediments to growth because of “shared identifications” were not identified in the data but, it does not mean it did not occur. To counter this risk, therapists ought to consider a reflective process to consider the meaning and nature of shared identifications individually so that they can understand and respond to clients individually.

Therapist’s trained in theories that highlight a neutral, apolitical stance, prioritizing a traditional hierarchical role of the therapist, may be more inclined to personify a “neutral technique that does not embody a particular worldview” (Avissar, 2009, p. 188). There was a sense throughout all the interviews that while deviation from this traditional stance might really be occurring in practice, neutrality was still held as an underlying precept and valued position. Certainly, this stance was still in use. Particularly, in the cases of divergent ideology, the therapists held onto a more neutral stance that was intentionally less revealing of their worldview. Keeping up a stance of the blank slate and traditional apolitical neutrality is challenged by modern socio-political realities and this creates room for these concepts to be re-imagined as we update theory to match actual practice.

Rosemary expressed more worry than others that she would be breaking the frame or blurring boundaries to acknowledge political content in a more personal way.

Rosemary’s responses illustrate the ambivalent feelings noted in the literature around the conflict of how to conceptualize and work specifically with political material (Samuels, 2004, Avissar, 2009, 2016, Milton and Legg, 2000). While Rosemary recognizes that her

161 clients know things about her implicitly, (she sees clients in the living room of her home,) she described herself as “conservative” in terms of her stance on self-disclosure.

Rosemary seemed to fit Samuels’ description of participants in his 1993 study. “…Many felt that it would be regarded as bad practice even though they wanted very much to engage more expertly with such material when clients bring it to the session” (Samuels, 2004, p. 828). In fact, Rosemary expressed to this researcher that her desire to participate in the research was, in part, to better understand how other therapists were dealing with the political personally and in session, ostensibly to learn from this. She expressed curiosity and did exhibit growth towards the end of interview process.

Helen revealed similar worries however, unlike Rosemary, it did not seem to stop her from experimenting and trying new things in session. Rosemary and Helen were both trained more than 30 years ago, and this researcher wonders if some of their concern in this area might be accounted for by the timing and traditional nature of their initial training, in combination with personal factors such as character, development, temperament and world view. However, no matter the amount of experience or timing of training, it seems as if the culture of psychotherapy still includes some indoctrination in the traditional position, even if an apolitical, neutral stance is not a full reflection of current practice. Helen acknowledged the experience of shame around her increased disclosures and spontaneity in session, but she understood this as insights to be explored, not necessarily as signs to stop the behavior. This conflict could complicate openly revealing clinical work that moves away from this stance because it may feel risky to share, particularly in the context of a single interview setting between individuals with no prior relationship or rapport. The younger participants in this study, who were trained in

162 the last 15 years and have less practice experience, seemed to share less concern about sticking to a neutral stance or offering a completely blank slate to clients.

Thoughtfulness and caution is used by therapists to engage in political discussion.

While all trained with knowledge of a traditional, apolitical stance, the political reality challenges holding fast to neutrality at times. As Alice notes, self-disclosure of the therapist is not the same thing as being, “more in relation to somebody.” The heightened environment created new terrain and therapists had to meet this with caution and creativity so that they could grow to meet the needs of the process. By monitoring and managing their own regulation around these issues they navigated new ways to use and share themselves in the treatment.

Recognition and being known.

Therapist subjectivity is revealed in any interaction and is part of any relationally based psychotherapy. This includes implicit, nonverbal and purposeful, explicit disclosures (Altman, 2010; Aron, 1991, 2005; Bromberg, 1994; Greenberg, 2001; Maroda, 1999). This research is predicated upon the idea that some self-disclosure is inevitable (Aron, 1991; Maroda, 1999). The therapists interviewed expected to be seen and understood by clients, even if they have not made explicit disclosures. There was acknowledgment by the therapists that their clients “know” them. Helen remarks, “That genie is out of the bottle,” explaining that between clients and therapist exists a, “familiarity, even if it’s not discussed.” She acknowledges that there is something implicitly known about her by her clients because, “there’s just something about how I am.” The consideration of what occurs between oneself and others is a primary aspect of

163 the theories grounding this research (Aron, 1996a; Benjamin, 1988; Stolorow & Atwood, 1996).

Participants talked about clients making assumptions about them and their political views with acknowledgement that this was connected to the attunement and intersubjective recognition that exists within the dyad. Natalie hypothesized, “But if they are as attuned to me as I’m trying to be to them, maybe they are sensing the subtle shifts and the openness to these conversations.…” Just as clients note the clothes the therapist wears, décor of the office, the race or ethnicity of the practitioner, so too, does the client note, consciously and unconsciously, implicit responses by the therapist. This can include a tiny nod, tilt of the head or a thin smile or smirk that might be elicited during sessions.

For example, widened eyes or nodding in agreement are both non-verbal behaviors that I noted in myself as I was interviewing participants and in my own practice with clients, as they describe scenarios in which I share affective responses. The participants here, as noted above, experienced a variety of physiological responses which could not be completely hidden from clients, nor was that necessarily the intention.

The implications of being “known” or being perceived as “known” by clients in the context of the political milieu seems to have resulted in a feeling of closeness, attunement and connectedness for therapists. Alice notes that while she does not generally disclose much about herself personally, she is “personable,” meaning that she shares herself with others without verbally sharing. She shared an example in which her client speaks with her in session as if they were at the Women’s March together. Alice conceptualizes that this as a way for her client to feel close and connect with her as a human, particularly in the face of a collective outside experience. Intimacy and relational

164 knowing in the therapeutic relationship during times of collective shared trauma is a way to explain how these “assumptions,” most of which were correct, emerged. Even Rosemary, who was least likely to admit to participating in political “discussion” in therapy, explains, “I cannot believe that they didn’t know how I stood… people I’ve seen for a very long time… like it’s based on the attachment we have.” Therapists felt experienced as whole by clients. Their clients brought politics up because they knew therapy was a safe place to share their feelings about these issues and often sensed a shared perception around the issues. In return, both members of the dyad feel more deeply understood. Therapists did not hide or making great strides to keep their positions under wraps when viewpoints were aligned.

The special circumstance of psychotherapy.

Any “discussion” of socio-political topics taking place in the context of psychotherapy changes the meaning of “discussion” from a commonplace conversation to a special therapeutic encounter. The fact that it occurs in treatment makes it different.

Avissar (2016) explains that political material, “…gets discussed as the client introduced it, as political material. Yet one cannot isolate engagement with narrow political contents from the context of therapeutic relations in which this discussion takes place” (p. 96).

Here, he points out that the presentation of political material in therapy cannot be divorced from the special and unique therapeutic nature of the relationship in which the material is emerging. An on-going collective traumatic reality outside of treatment inevitably makes its way into the conscious, unconscious and collective experience and thus, into therapy. The therapeutic frame must be constantly updated and re-defined to

165 hold and make meaning of this material in therapy, requiring flexibility and creativity on the part of the therapist.

Modell (1989, 1991, 2009) suggests that the therapeutic setting is an “area of illusion,” characterized by reality and symbolism simultaneously. Participants offered clients an opportunity to move between realities within the special frame of the therapeutic relationship. Clients had room to imagine, assume, wonder, and “know” their therapist as a representative of various realities. The participants gave them room to project what was needed into the space as evidenced by their experience that clients needed to make assumptions about their political positions at times. Modell (1991) suggests that the function of neutrality supports the boundaries of therapy so it is worth exploration to consider how increased self-disclosure impacted boundaries. The special circumstances of the heightened external world events tested and maximized the use of boundaries but, were also mitigated by the fact that therapists have awareness that they were not engaged in ordinary dialogue. Therapists do not treat the political “discussions” the same way they would if they were venting with their friends. They paid attention to the context and this changes the meaning of what occurs. Alice tried to describe what it is like as the therapist to hold boundaries within the context of the special reality of the therapeutic frame, “…that way you have to metabolize something really quickly to be present for someone else’s experience but you’re still feeling it.” In therapy, the political can be personal and collective simultaneously. Avissar (2016) explains “political discourse changes meaning when it occurs in psychotherapy. Since, in therapy, political subject matter will blend in with the therapist’s and the client’s psychological processes, their significance will be personal and collective at one and the same time” (p. 94). It is

166 likely that for the participants, some aspects of political discussion with their clients did gratify a personal need to share in and mutually console one another around aspects of collective trauma, offering relief. However, this does not minimize the special meaning of discussion in the context of therapy. This participation enhanced closeness in the therapeutic relationship, making space for new growth. Farber (2018) adds, “therapists should also understand that their own involvement in such discussions – while traditionally eschewed – may well strengthen the alliance and further clinical progress.

As the personal is political, so may the political be intensely personal” (p. 720).

“Discussion” or interaction around the political in session challenges therapists to grow and meet persistently moving reactions to the continual, highly charged world around them and their clients. It could be useful to qualify “discussion in psychotherapy” as different from the word “discussion” because they are not the same.

Intimacy.

Outcomes of commiserating or sharing in something together in psychotherapy can lead to increased feelings of closeness, intimacy, and attunement. Farber (2006) offers a conceptualization of why individuals disclose to one another and this description is consistent with the data collected here.

In short, we disclose in order to feel closer to another, to feel validated by another, to understand and strengthen the core aspects of our identity, to explore and accept multiple aspects of ourselves, to feel more genuine in the world and to relieve the burden of unexpressed pain. (Farber, 2006, p. 13).

167 During times of collective strife, enhanced authenticity, intimacy, and closeness may be a necessary component for healing, and so it is no surprise that the therapist-participants gravitated towards interventions that enriched these aspects of the relationship (Tosone, Nuttman-Schwartz, & Stephens, 2012, Tosone, 2006, 2011). Sharing in anxieties around the environment was generally a new experience for these therapists and challenged them to adapt and find new ways to manage and hold the integrity and boundary of the therapeutic relationship while “joining,” “loosening”, and/or “commiserating” with clients. As a result, they experienced personal and professional growth. Aron (2006) suggests the use of the concept of a “third” in psychotherapy to manage identifications and differences, “opening up psychic space for self-reflection and mentalization” (Aron, 2006, p. 350). This concept might describe what occurred in some of the circumstances described by participants. The collected shared traumatic reality became a “third” in the therapy.

Post traumatic growth.

Post Traumatic Growth is the concept that positive psychological change can be an outcome of extremely challenging circumstances (Tedeschi & Calhoun, 2004a, 2004b; Ramos & Leal, 2013). The increased intimacy and closeness described by therapistparticipants matches the mix of distress and growth found after other shared events, such as 9/11, missile attacks in Gaza and hurricane Katrina. Baum (2010, 2014) found a relationship between shared reality and the experience of both distress and growth for clinicians. The current assaults on safety, security and the chronic social and political circumstances make this literature valuable. Findings here are consistent with aspects of

168 post traumatic growth in that therapists also experienced, “increased compassion and connectedness with clients” (Bauwens & Tosone, 2010, p. 498).

Four of the five therapists described experiences of enhanced closeness and attunement, Rosemary being an outlier here. Daniel described the effect of disclosure as an experience of “joining” while Alice described that recent events have led to a feeling of “commonality in the relational space.” Natalie described, “a closeness with more attunement,” and Helen noted that this has been, “a bonding experience.” Odgen’s (1997, 2004) theory of the analytic third, entirely different from Aron’s use of the “third,” may help to explain what is occurring here. Odgen (2004) explains, “experiences in and of the analytic third often generate a quality of intimacy” (para. 44). The use of reverie to be in touch with the unconscious, co-created, intersubjective space in therapy allows the therapist to better understand client’s needs, wishes, experiences and inner life. Helen describes how during sessions she thinks and listens simultaneously for emotional content and the results are increased closeness between client and therapist. This increased therapeutic responsiveness during times of dysregulation by both therapist and client is a noteworthy outcome.

Variation in the timing of responses and spontaneity with which therapists replied to political material is another aspect of growth and change. “…this whole political thing has sped it up a little bit… I feel looser, more comfortable… I’m commiserating and I think they appreciate it,” Helen explains. Helen’s background is very psychoanalytic and she spoke at length during her interview about her very traditional training background in which, “you’re not supposed to say much.” She reported that she finds herself increasingly overtly responsive to the courage her clients embody. While this is not

169 specific to political content, it is noteworthy because it is out of the context of insight and reflection around political issues that Helen noticed this growth in herself. It is also not a political because her spontaneity and responsiveness to client examples of courage can be considered part of the broader definition of what “political” encompasses.

Development The constant comparative method of data analysis found that each participant experienced development personally and professionally either, as a result of working with political material in therapy, the interview process, or interacting with politics personally.

Research on therapist development (Orlinsky and Ronnestad, 2005) explains that learning through experiences in therapy with clients have the most important impact on therapist growth and development (p. 128). As fundamental trust in the country’s leadership has eroded, feelings of individual safety and security have left people feeling exposed and threatened. This highly charged, collective experience, requires that therapists acknowledge and engage with authenticity, particularly when they are feeling things too.

Judy Leopold Kantrowitz’s (1996) found, “…that the intensity of personal engagement and opportunity for personal change occur when there is an inderdigitation of conflict, personal characteristics, or both between analyst and patient” (p. 101). Participants were willing to engage in increased spontaneity. When warranted, they used their whole selves to be responsive to new clinical situations, regulating both themselves and others in the face of distress, and co-inhabiting and creating new relational spaces with their clients.

Politics’ penetration into the psychotherapy space is not only an opportunity for growth and development for individuals but also the professional practitioner.

170 This growth and development did not divorce the intrapsychic from the interpersonal. As Layton (2006) suggests, a traumagenic environment facilitates the “interpenetration of subjectivity and sociopolitical order” (p. 6). Client’s distress about politics was not seen as a statement of their inner workings that ought to be interpreted or seen in a vacuum away from the reality of the world, nor was every statement or discussion about politics viewed as a sentiment about a shared world view. Therapists toggle between conceptualizing their clients with expertise, understanding that one aspect cannot be disconnected from the other. The therapist-participants adapted with responsiveness to the client’s struggles while simultaneously struggling at times with similar thoughts and feelings. As the client’s find mastery and regulation around this material so, too, does the therapist which is consistent with Kantrowitz’ (1996) findings that therapist growth occurs through “identifications and counteridentifications” (p. 215).

In this circumstance, these identifications are around a third, shared experience with reality.

The voluntary election to participate in the interview process signals curiosity around the topic and interest in participating in reflective experiences that increase insights. This may indicate that these therapists are open to growth. All the participants seemed glad to have the chance to discuss and make sense of how they had been responding and working with the political personally and in their practice. The interview process helped them to review what they were doing, understand and explore their unique experiences and make sense of their growth.

Daniel’s response to the election in 2016 prompted him to become extremely politically active. Now, he is a community leader and activist simultaneous to his

171 profession role as social worker. This new responsibility and the intensity of his convictions signify growth and personal development for him, since he was not very politically active before 2016. It also requires him to engage in thoughtful consideration of the impacts and effect that this has on his clinical practice. He notes that he has grown in his ability to manage and differentiate between the needs of the community from the individual needs of his clients. Daniel understands that his activist-self cannot be completely hidden from his clients, even if he keeps it private. The ramifications of this have challenged him to grow. He holds a stronger belief than the other participants that it is warranted to inquire about a client’s relationship to the political surround and feels an overt obligation to consider a client’s inner political self as part of his conceptualizations.

Of the interview process, he noted some discomfort at being so revealing.

Natalie’s growth seems more centered on the development of increased intimacy and attunement with clients. Her answers reflect a sense that she feels freer to use herself and spontaneity in the process with clients and trust her clinical judgment. During the interview, Natalie reflected upon an intake with a client with opposing views and that her attempt to offer neutrality and attunement seemed to fall flat because she held back from the client’s desire to engage her in discussion of her ideals. This example exemplifies how difficult it can be to find recognition and attunement without authenticity. Of the interview process she found the, “conversation is gonna help me reflect for days to come” indicating continued growth because of her participation in the research process.

Rosemary grew throughout the interview process. Her participation reflects her interest in developing herself and seeking out on-going education. While her answers were challenging to analyze, her presentation may indicate how she was processing her

172 own understanding of the political for herself and in her practice in real time during the interview. She acknowledged that the upset of the election brought up questions for her about her practice and began to wonder aloud towards the end of the interview if there might be reason to assess clients for information about their political ideas. “I don’t know whether I will bring up, “are you politically active?” in my history taking… That question, is this a part of life that is something that would be a reasonable thing for me to just bring up?”

Alice and Helen both shared insights around how their style, demeanor, and professional stance shifted and grew over time. They both came to the interview with awareness that growth and development is inevitable. Each reflected upon their expanded use of self to shift and change, as dictated by the needs the client. They also grew personally. Alice discussed her personal challenge to find the space to “participate” in politics in her own way, ultimately finding mediums like meditation, writing, and quiet spaces. Alice and Helen both found the interview process useful in that it offered space to “think things through.” Helen noted her growth in terms of her tendency in session to more explicitly acknowledge aspects of client’s experiences as well as increased spontaneity and commiserating as a new style in the clinical space.

This dissertation began in chapter one by noting my own personal experience and interest in the topic. It seems reasonable then to circle back and note that I too, have experienced growth and development in response to the research process. Just like my participants, I also have developed and grown in my understanding and conceptualization of the use of spontaneity and authenticity with respect to political material. I am much more aware of listening for and responding to politically laden content with ease and

173 confidence, and I find that this has enhanced intimacy with some clients and contributed to client reflections of their civic-selves in therapy. Interviewing participants gave them an opportunity to reflect on their experiences and it also allowed me to have my own responses to their stories, enhancing and informing my world view and practice.

Final Thoughts The humanity of psychotherapy.

The general political ideology of the therapist-participants was in alignment with the assumptions often made about social workers and psychotherapists as “left leaning” (Tolleson, 2012; Layton, Gutwill & Hollander, 2006; Murdach, 2010; Roswenwald and Hyde, 2006; Rosenwald, 2006). Participant’s chose to pursue social work and psychotherapy partly because of its alignment with the participant’s personal beliefs and values. Social work and psychotherapy strives to improve mental health, which is political. Professional codes of ethics’ take a stance on issues of equality, human rights and social and economic policy. Daniel explains, “You’re having this problem inside a system, and the system is political and maybe the solution is not to change yourself, but to change the system.” Benitez-Bloch (2013) describes the necessity of acknowledging individuality and membership in society, We want our work with patients to inform us so that we feed into our professional affiliations to link our knowledge base and our clinical experience with social policy as steps toward dissolving the paradox between inner and outer worlds. (p.

39)

174 This raises questions about the necessity of participation in the larger political system by the profession. An example of this can be seen recently in the volume, The Dangerous Case of Donald Trump, (Lee, 2017), which was conceived as the result of a conference on the issue of “Duty to Warn,” focused on the risks associated with the current administration. If professionals, trained to listen and assess for concerns about safety, health, and danger observe concerns, do they have some ethical or moral obligation to speak up? In 2004, Adrienne Harris questioned American psychoanalysis’ consideration of reality and the outside world, “So it is perhaps an American question to ask how this rupture in inner and outer security will constitute a moment in which psychoanalysts rise to the occasion of contribution to the public debate” (Mitchell and Harris, 2004, p. 187).

Although this was written in 2004, her reference to the jeopardy of inner and outer security and questions about the participation of the profession is extremely relevant today.

The findings only consider experiences in the world that occurred prior to the interviews but the socio-political world continues to evolve. This research functions as a snapshot of taken during the experience of something that continues to remain in motion.

The limitations of the study’s structure of one-time interviews impeded the ability to make further conclusions about the ongoing impact of this phenomenon. One can infer that the shared reality is an ongoing, ever changing situation that constantly impacts therapists, clients and the treatment relationship. Therapists have an obligation to continue to grow and develop to match this ever-evolving reality. This growth experienced did not occur on a whim, it was necessary, grounded, and consistent with how psychotherapy works. The results exemplify the humaneness of the therapeutic

175 relationship. Therapists found that they acknowledged their humanity in new and different ways when challenged by similar conditions as their clients. While therapists managed boundaries, kept their clinical judgment intact, and put the needs of the client and the individualized therapeutic process first, they were forced to grow and develop ways to work with and conceptualize this new shared dynamic. Natalie explains, “there is something really freeing… and it does feel like a political act sometimes. Like, above all, we’re human. We’re humans who have a relationship.” Alice concurs and uses similar language, “It feel like in that real of things it makes us more human…leveling the playing field.” Violette (2013) speaks to this when she suggests that psychotherapy training ought to consider “our cultural embeddedness so that we might be able to find some ways to connect the psychoanalytic understanding of the person (awareness of the unconscious) to the ethical questions of being a person in the larger world” (p. 82). This brings up the question of how therapists view the function of psychotherapy and if a goal of psychotherapy can be the development of the connection and insight around an inner civic-self.

Psychotherapy as a political action.

The uniqueness of the therapeutic relationship and the psychotherapy space is an opportunity for individual political development and the action of psychotherapy might even be a political act itself. Avissar (2016) highlights the impact that therapeutic exploration can have on the individual and likely the therapeutic dyad as well. “Once the barrier between the political and the personal begins to come undone, the psyche is likely to reveal itself as more political than it seemed and this in turn is likely to subvert (what

176 was hitherto stable and unquestioned), to clarify (self-experience), or to lead to change” (Avissar, 2016, p. 94). Therapy is political if it questions what was previously unquestioned and leads to enhanced insight and change for the individual. Further, the ramifications of individual internal development must result in changes for society. As individuals are more developed and insightful, they may activate their human potential, resulting in greater participation and enhanced, more secure relationships with others and the world; creating a ripple effect. This research contributes to the profession because its findings add to our cannon of literature but also, and maybe just as importantly, the process of the research interviews themselves might be understood as a political action.

The process of interviewing participants acted as a consciousness-raising activity both for the participants and for me. The participants used the interview to reflect and consider their experiences and this deepened their understanding of themselves and others and influenced the subjectivity they offer others. Their growth is not apolitical since that same growth will inform how they interact with others in the future. Every participant shared personal dismay at the current socio-political situation which meant that the interview experience also doubled as an experience of collective and shared reality between participants and myself.

Cushman (2015) makes the case that participation in a relationally based therapy, “either as a therapist or a patient might mean that one has begun preparing oneself for, or has enrolled in, a subtle school for political resistance” (p. 450). He explains, “This is because its practices can enable a way of being that is honest, self-reflective, critical, humble, curious, compassionate, and respectful of and willing to learn from difference” (Cushman, 2015, p. 424). The idea that a therapist is working with others to improve the

177 quality of their life and experience, as a political action, was not explored in depth during the interview process but is worthy of consideration. Alice does offer remarks that touch on this area, “…As therapists I really do believe everything we do is value driven… you can’t separate out at this point what’s going on in history of this country and the world.”

One might argue that the choice of psychotherapist as a profession has some inherent aspect of activism in it. The findings also suggest further consideration of questions posed by Eyal Rozmarin (2017b) after the election. He explores the question of how or if psychoanalysis explores the “…social forces that structure our very being and underwrite our lives” (p. 459) and wonders if psychoanalysts “should” hold a “particular political position or sensibility?” (p. 460). The special nature of psychotherapy and the relational position of therapists, means that politically laden sensibility cannot always stay hidden in the circumstances of a shared, collective traumatic reality. Ultimately, this leaves me thinking even more deeply about my own interest in this topic and my personal and professional growth resulting from of my clinical work, the development of my own civic activism, and my participation in the dissertation process. Being immersed in this literature for two years has left me feeling much more aware of my own political ideas, values and opinions. Like the participants, I too, have noted spontaneity and increased sharing around the collective reality, tracked my regulation and that of my clients in session, and have had experiences of greater intimacy and closeness.

Limitations There were several limitations that impacted this study. The small sample size and lack of diversity within the sample in terms of race, class, culture and political ideology

178 inhibit the ability to consider a variety of perspectives in the discussion. While some diversity in clinical experience, age, and professional background is present among participants, this did not extend to other aspects of diversity. It is unfortunate that there were no responses from therapists who presented with a more politically conservative point of view. One can speculate that the pool of therapists who support the current Republican administration in the Southern California area is smaller and were not reached by my networking efforts. They also may not have been attracted to participate.

A larger study with more diversity of perspective for both the participants and their clients might offer opportunities for further inquiry and more depth in the results.

Another limitation is the expansiveness of the material obtained by the semistructured interview that was used for this study. The sample size combined with research questions that were too large in scope may have inhibited the data from fully reaching a saturation point. The methodology procured results that encompassed a large amount of material. Posing fewer, more specific research questions might have allowed more focus in the results and discussion.

Meeting with participants only one time limited any ability to follow up, to consider how the responses changed over time, or in relation to the changing world around the participants. For example, while this writer did note that power and power dynamics are included in a definition of “politics,� this did not emerge in the hour-long interviews in a direct way, limiting the discussion of this area. This could be due to the heavy focus on the current U.S. politics as opposed to issues of power in therapy, as well as the lack of a direct question in the interview guide which would probe the topic.

Similarly, while the participants did offer data about what drew them to the profession,

179 the scope of the project, limited responses, and lack of follow up questions leave a less than optimal opportunity for full discussion. The nature of a single hour long interview is limits the results. Lack of opportunity for follow up leaves many areas open for further study, some which will be addressed in the section below.

Recommendations for Further Study The context of a heightened external shared reality is a special circumstance that has clearly made its way into the psychotherapy space. However, there is still much to discover about the implications and ramifications of political issues in the psychotherapeutic space. Future studies could address some of the limitations noted above by engaging in larger studies with more diverse participants from more diverse regions of the country. Considering methodology that includes follow up or multiple interview sessions might offer opportunities for more depth or specific follow up.

It would be useful to develop more understanding about the process by which therapists may feel tied to operating with “rules� about disclosure or around political content in the context of shared circumstances and ideology. Do these therapists also see themselves as flexible or liberal? In this study, the newer/younger participants seemed less reflective or concerned with how their stance with clients had changed and they seemed more open to disclosures about shared ideologies with less angst. Further research ought to consider and better understand this. How does the timing, location and training influence the therapist’s stance on these issues and how they manage flexibility?

It could be useful to better understand more about possible boundary and relational shifts that might be tied to new ways of communicating (social media, texting, email, video)

180 have changed and impacted therapists with all levels of experiences. Would the results of this study differ if the participants had less clinical experience, more recent training, or had different theoretical backgrounds?

Further studies should look at the ramifications of managing a 24-hour news cycle in the context of heightened socio-political collective trauma. Long-term studies that consider the implications of therapist disclosure in a shared reality over time is warranted.

What is the long-term effect of the enhanced intimacy, connectedness and attunement felt in the dyad? How long does this last and what happens in the treatment when one member of the dyad changes their position or there is a rupture in the relationship? What happens when assumptions about ideology exist between therapist and client? What is the risk and impact of over-identification between therapist and client and how do we know when this is happening? When the clinical dyad does not agree about something, does it affect issues of power in the relationship? How do therapists think about this and respond?

Other questions that this study brings up, but does not answer includes: How will the experiences of the last three years inform the way therapists work with clients throughout the next election cycle? Further inquiry about the usefulness and implications for direct assessment of “the political� with clients might also yield informative data.

Future studies on the impact of shared vs. divergent political ideas between therapist and clients will offer more insight into the long-term impact of this phenomenon on therapy.

While the participants did offer some detail about why and how they chose their profession it would be useful to dedicate research to learn more about the underlying personal political action behind choosing psychotherapy as a profession.

181 The data here only considers experiences from the therapist’s perspective. It would be useful to include research that looks at the client’s experiences in therapy as well. Finding opportunities to look more specifically at the impact of psychobiological regulation and dysregulation in the context of this material would be an important and interesting area of further research. There is still a lot of spaces to uncover more about how the shared trauma and similar and differing ideologies create complications and challenges for therapists.

Contributions to Field of Social Work Considerations about the use and implications of disclosure must continue to be addressed in ongoing education. Therapists should be encouraged to reflect upon how they and their practice are impacted by the ongoing environment on a regular basis. It is the process of reflection that offered participants in this study the opportunity to make sense and develop insight about their own changing responses over time. It would be useful for clinicians to discuss with one another their experiences, as the process of making space to reflect and develop insight was tied to therapist growth. There is room, too, for the profession to reflect and consider how they shape and train new therapists to look, listen and interact with politically laden material.

This work contributed to the field of social work by acknowledging the unprecedented impact of the current environment and the relationship between experiencing and acknowledging a shared reality and therapist growth and development.

By analyzing the open-ended responses from five therapists, one can consider some of the therapist’s experience of the political in psychotherapy. This work helps to debunk

182 any myth that political issues are absent from a psychotherapeutic process and in fact, supports the use of a thoughtful relational approach as useful in this context. Milton and Legg (2000) suggest a stance that considers the reflexive nature of theory and this research supports the need for continued application of this view towards clinical work as the socio-political reality is on-going, never-ending, and constantly changing. Even those with a traditional theoretical stance may find that an orientation that is politically sensitive will enhance their practice. Additionally, therapists have a responsibility to reflect upon their own beliefs and ideals in an ongoing manner. Just as our clients may grow and develop their civic selves, therapists will also find their reactions and responses to the environment changes over time. Therapists must be trained to not only understand where they stand personally but how those personal stances might infuse their relationally based therapeutic relationships. The discussion offered in this work will help other clinicians develop insight and track their own growth and development in this area.

Conclusions My own similar reactions to the same external socio-political reality as my clients contributed to a heightened sense of shared experience and mutuality within the therapeutic relationship that felt different and unique for me. My own need to make clinical adjustments and bring attention to this phenomenon in my practice prompted me to investigate and learn more about the psychotherapists’ experience of the political in psychotherapy. Immersing myself in the literature and developing the findings has had a profound impact on my practice.

183 The original question considered how therapists respond to, work with, and conceptualize political material that emerges in psychotherapy sessions and the findings offer a deeper understanding of the impacts of a shared reality on therapist development.

Ultimately, the experience of sharing in a collective and at times, traumatic and dysregulating external reality challenges therapists to grow professionally and personally.

The results highlight that from the perspective of therapists, a shared reality can increase authentic, spontaneous responses in the therapy which enhance closeness and attunement.

Therapists do consider both a client’s intrapsychic world as well real-life considerations.

In the context of the emerging pressures of the outside world, the therapists rose to this challenge with flexibility and creativity. They expanded the frame of the therapy space to include spontaneity, authenticity, judicious use of disclosure and mutual regulation. This served to deepen attunement and acknowledge that implicit knowing exists in the special nature of a therapeutic relationship. The therapists used the interview process to reflect upon their own relationship to the political, including their political participation, and how the puncture of the therapeutic space by the outside world impacts their interventions. All of this occurred while the world continues to evolve, reinforcing the notion that theory and practice must continuously develop and reflect upon how to meet the needs of the eternally shifting world.

184

Appendix A: Sample Recruitment Letter

185

Email to Personal Contacts Dear ______________________, As you may be aware I am currently a doctoral student at the Sanville Institute for Clinical Social Work and Psychotherapy working towards my PhD in clinical social work. I am working on my dissertation project and am ready to recruit participants for my research.

My research question looks at how therapists conceptualize and work with political material in psychotherapy sessions. I would like to better understand what therapists consider as “political,� if/how/when it does come up, how they respond and think about it.

Participants will meet with me for a 60-90 minute in person open ended interview in which they will be asked to elaborate on their personal and professional experiences.

All measures will be taken to insure confidentiality of both the interviewee and any material they share.

I am writing to you today to ask for your help in soliciting participants for my study. I am looking for 5-7 therapists working in a private practice who consider their approach to be psychodynamic psychotherapy to interview.

If you know anyone who might fit the description above or might be interested in speaking about their clinical and personal experiences working with political material in their practice please pass along my contact information. You can also contact me with referrals and I can reach out directly to your suggestions.

I appreciate the time and energy spent helping me to complete this project and thank you in advance for all your help.

Sincerely, Jennifer Bulow, LCSW

186

Appendix B: Advertisements and Posts for Recruitment

187

Advertisement in professional newsletters: SEEKING RESEARCH PARTICIPANTS Seeking licensed therapists (LCSW, PhD, PsyD, MD, MFT) in private practice to participate in interviews for research study about looking at how therapists conceptualize and work with political material in psychotherapy.

Please contact: Jennifer Bulow, LCSW, doctoral candidate at The Sanville Institute for Clinical Social Work and Psychotherapy (323) 823-4147, jb@jenniferbulow.com For postings on professional listservs, email groups, Facebook groups, websites: SEEKING RESEARCH PARTICIPANTS: Seeking licensed therapists (LCSW, PhD, PsyD, MD, MFT) in private practice to participate in interviews for research study looking at how therapists conceptualize and work with political material in psychotherapy.

If you, or someone you know might be interested, please contact Jennifer Bulow LCSW, doctoral candidate at the Sanville Institute for Clinical Social Work and Psychotherapy (323) 823-4147 jb@jenniferbulow.com Feel free to refer colleagues for this study as well.

188

Appendix C: Sample Letter/Email to Prospective Participants

189

Dear _____________, Thank you so much for expressing interest in participating in my doctoral research study.

OR: ________ suggested I contact you as you may be interested in participating in my doctoral research study.

I am a doctoral candidate at the Sanville Institute for Clinical Social Work and Psychotherapy. My dissertation research will be conducted under the guidance of Principal Investigator and faculty member Samoan Barish, Ph.D. and secondarily by faculty member, Judith Schore, PhD. My research question asks how therapists conceptualize and work with political material in psychotherapy sessions. I would like to better understand what therapists consider political, and if or when it does come up in session, how they conceptualize and respond to it, what is the impacts on the therapy, therapeutic relationship, and on the therapist personally.

I am looking for psychodynamically-oriented clinicians, in private practice settings, who are interested in elaborating and reflecting upon their clinical work, and sharing personal and professional experiences and real-life examples in a 60-90 minute in person interview.

Participation in the study involves filling out the attached questionnaire, to determine eligibility, and then, if accepted, a personal interview would be scheduled at a location that is convenient for you. If you are outside of the Los Angeles area, we will discuss the most convenient logistics for completing a face to face interview. There may also be a brief follow-up phone call after the interview, if something requires clarification.

I hope that your participation will deepen your own understanding of the political in psychotherapy practice. I will be happy to send you a summary of the research results upon completion of the project.

I have enclosed a copy of the Consent Form for your review. At the time of the interview I will answer questions about the consent and we will sign it at that time. I will take measures to ensure the anonymity and confidentiality of your information, as well as keep confidential any client material you may discuss. This applies both to the dissertation and any future papers, presentations or publications on this subject matter.

This process also requests that you assign your clients pseudonyms for our discussion and disguise any recognizable material.

If you willing to participate in the study, please complete the brief questionnaire attached and return it to me as soon as possible either via email or in the enclosed self-addressed envelope.

190 Once I receive the questionnaire, I will be in touch shortly regarding the possibility of your participation.

Please feel free to contact me directly if you have any questions. I look forward to speaking with you.

Sincerely, Jennifer Bulow, LCSW

191

Appendix D: Prospective Participant Questionnaire

192 Prospective Participant Questionnaire Name: ____________________________________________________ Address: ___________________________________________________ Phone: Work___________________ Cell __________________________ Email: _________________________________________________ Please note the best way to reach you: ____________ I am interested in participating in the research and available for a 60-90 minute interview: Yes ___ No __ Professional license and year of licensure: LCSW: _________; PsyD: ___________; MFT:___________ PhD: ___________; MD: ____________ Address of your private practice: _________________________________________ Number of years in private practice: ______________ How would you describe your theoretical orientation? ___________________________ ________________________________________________________________________ ________________________________________________________________________ Are you willing to discuss personal and clinical experiences during a 60-90 minute in person interview? Yes ________ No __________ Not Sure ___________ If not sure, please explain: __________________________________________________ ________________________________________________________________________ Thank you for your willingness to consider participation in my study. I will contact you about further steps as soon as possible.

193

Appendix E: Sample Letter/Email for Prospective Participants Not Accepted for Study

194

Dear _____________, Thank you very much for expressing interest in participating in my research study on politics in psychotherapy. I have recruited enough participants to begin the study, and will not need to schedule an interview with you. If the situation changes and I need to interview additional people, I will contact you to see if you are still interested and available.

If you are interested in my research findings and would like me to send you a summary of the research findings, please feel free to let me know.

Thank you again for your interest in my work.

Sincerely, Jennifer Bulow, LCSW

195

Appendix F: Sanville Institute Informed Consent Form

196

Sanville Informed Consent Form I, __________________________________________________, hereby (name of participant) willingly consent to participate in the qualitative research project on how therapists conceptualize and work with political material in psychotherapy sessions. This research project will be conducted by Jennifer Bulow, LCSW under the direction of Samoan Barish, PhD, Principle Investigator and faculty member, Judith Schore, PhD, and under the auspices of The Sanville Institute for Clinical Social Work and Psychotherapy.

I understand that my participation in this study involves completion of a brief written questionnaire and introductory phone call to determine my eligibility for the study. If selected to participate, I will participate in a 60-90-minute face to face interview that will be recorded and transcribed. The interview will take place in a confidential setting agreed upon by interviewer and subject. I will be asked to speak about my personal experience and am only required to share what I determine. If necessary, a follow up phone call may be conducted by interviewer for clarification.

I understand I will be discussing my clinical experiences within my psychotherapy practice, my personal experiences, and my own internal thoughts, feelings, observations.

Risks and Benefits: I understand that the potential risks of my participation may include:  There is risk that talking about this subject could make me feel uncomfortable or bring up feelings for me that I was previously unaware.  I may experience emotional discomfort and if this should happen during the interview, I will let the researcher know about my reaction and we will determine together how to proceed.  After the interview, if I feel upset or uneasy, I can contact the researcher for help in processing any feelings that emerged during my participation in the study, or can ask for a referral to an outside therapist, if that is desired.

The benefits to participation may include:  I may reflect upon my own feelings about these themes and issues and develop some insight or deepen my awareness around them.  The experience of reflection during the interview may enhance my personal awareness and clinical practice.

Voluntary participation: I understand that my participation in this project is completely voluntary and that I may withdraw from the study at any time by discussing with the interviewer my discomfort and request for withdrawal.

197 Confidentiality and use of information: I understand that this study will be used for a qualitative research dissertation. I also understand that my anonymity and confidentiality, and that of any client I may discuss, will be protected in in the dissertation as well as any future article, presentation, published or unpublished work that is produced because of the research. The researcher will require that I assign any client names with pseudonyms and disguise all identifying information and unique descriptions to protect both client and myself. The same confidentiality standards will be applied to me, removing my name and any specific identifiable information, assigning me an interviewee code or pseudonym to protect my anonymity and confidentiality. Further, some scenarios I discuss in detail in the interview may be summarized to generalize and protect my anonymity. The audiotape of my interview will be erased 6 months after completion of the dissertation. Only the researcher, the Principal Investigator, the additional members of the dissertation committee, and transcriber will have access to the oral interview.

My signature below indicates that I have read the above explanation about my participation in this research study, that I understand the procedures involved and that I voluntarily agree to participate.

Participant Name: ____________________________________ Participant Signature: _________________________________ Date: _____________

Researcher Name: ___________________________________ Researcher Signature: ________________________________ Date: _________

Would you like a summary of the results of this study?

Yes: _____ No: ______ If yes, please include address or email where you would like the summary sent: _______________________________________________

198

Appendix G: Cover Letter for Re-Consent of Participants for ICSW Program

199

Cover Letter for Re-Consent of Participants Dear ___________, I hope this message finds you well. I am so grateful for your participation in my dissertation research and I am writing to offer you a brief update on my work as well as ask for some needed help.

I have completed my research and organized my data. I am now working on writing a discussion of my findings. I anticipate that I will be ready to defend my work by the first half of 2019. Your participation has offered me rich material with which I suspect will offer a deeper understanding of the topic. I am so grateful for the time we spent together.

However, in the new year, there will be some changes in the Institution with which I am affiliated. Sadly, due to changes in the requirements for California higher education accreditation, The Sanville Institute, will be closing in December 2018. I will be transferring to an accredited institution based in Chicago to complete my doctoral studies, The Institute for Clinical Social Work (ICSW). There I will be able to continue my research as planned and graduate with a PhD in clinical social work, as planned. My research will continue to be under the direction of Principle Investigator and faculty member, Samoan Barish, PhD and my original committee members and I will add additional members from ICSW to my committee as well.

I am writing because I need to ask you to re-consent for me to use your interview data under the auspices of ICSW. ICSW has an in-house Institutional Review Board with a Federal Wide Assurance (FWA). A Federal Wide Assurance (FWA) is the documentation of an institution’s commitment to comply with Federal regulations and maintain policies and procedures for the protection of human participants. An institution must have an FWA in order to receive Department of Health & Human Services (DHHS) support for research involving human subjects. This is the principal mechanism for compliance oversight by the Office for Human Research Protections. The FWA number for ICSW is IRB0007789 and is active through 10/12/2021. Their profile may be viewed at https://ohrp.cit.nih.gov/search/IrbDtl.aspx. It is important to note that in the re-review of my study application by the ICSW IRB Panel very few changes were made to my original application and consent form. The designation for my study made by the ICSW IRB panel is below minimal risk.

To continue and complete my research I must receive the attached consent form completed from you before the end of the year. If you have any further questions regarding this change and request, you may contact me directly or call Dr. John Ridings (ICSW IRB Chair) at 773-263-6225. I have attached the form here but I will also mail you copy along with a stamped, self-addressed envelope so you can easily return it to me.

200 Please let me know if you have any trouble completing or returning this new consent form to me. It is necessary for me to receive it in order to continue to use your interview as part of my project.

Thank you again, Jennie

201

Appendix H: Institute for Clinical Social Work Research Information and Consent for Participation in Social Behavioral Research

202 Leave box empty - For office use only

Institute for Clinical Social Work Research Information and Consent for Participation in Social Behavioral Research The Therapist’s Experience of Politics in Psychotherapy I, , acting for myself, agree to take part in the research entitled The Therapist’s Experience of Politics in Psychotherapy.

This work will be carried out by Jennifer Bulow under the supervision of Dr. Samoan Barish.

This work will be conducted under the auspices of the Institute for Clinical Social Work; At Robert Morris Center, 401 South State Street; Suite 822, Chicago, IL 60605; (312) 935-4232.

Purpose The purpose of this qualitative research study is to explore therapists’ experiences and clinical exchanges regarding political material in psychotherapy. Using a Grounded Theory approach, data will be collected by conducting in-person, in-depth, semistructured, open ended interviews with 5 psychotherapists who work in a private practice setting and self-identify as including a psychodynamic approach to their clinical work.

The research question asks how therapists respond to, work with, and conceptualize political material that emerges in psychotherapy sessions. Therapists will be asked to elaborate on their personal and professional experiences and share what they determine to be political material, including detailed clinical vignettes. Therapist responses will offer an opportunity to develop insight, recognize and discuss meanings, and consider the potential impact of personal and clinical interactions surrounding the political.

Considering the recent chronic, heightened socio-political external environment, concepts of shared reality and self-disclosure will be considered. The findings may offer opportunities for the profession to better understand a phenomenon and consider the possible ways theory and practice models might be updated to meet the ever-evolving needs of clients and therapists.

Procedures used in the study and duration I will require you to complete of a brief written questionnaire and an introductory phone call to determine your eligibility for the study. If selected to participate, you will asked to participate in a 60-90 minute face to face interview (or via video conference if outside of Los Angeles) that will be recorded and transcribed. The interview will take place in a

203 confidential setting agreed upon by interviewer and subject. You will be asked to speak about your personal experience and will only be required to share what you determine. If necessary, a follow up phone call with interviewer may be conducted for clarification.

Benefits The benefits to participation include that I may reflect upon my own feelings about these themes and issues and develop some insight or deepen my awareness around them. The experience of reflection during the interview may enhance my personal awareness and clinical practice.

Costs Aside from time and travel, you will endure no direct costs for your participation.

Possible Risks and/or Side Effects I understand that the potential risks and benefits of my participation include: There is risk that talking about this subject could make you feel uncomfortable or bring up feelings for you that I was previously unaware. You may experience emotional discomfort and if this should happen during the interview, you can let the researcher know about your reaction and together you will determine together how to proceed. After the interview, if you feel upset or uneasy, you can contact the researcher and request can request a referral to an outside therapist, if that is desired.

Privacy and Confidentiality I understand that this study will be used for a qualitative research dissertation. Your anonymity and confidentiality, and that of any client you may discuss, will be protected in any future article, presentation, published or unpublished work that is produced because of the research. I will require that you assign any client names with pseudonyms and will disguise all identifying information and unique descriptions to protect both your client and yourself. The same confidentiality standards will be applied to you, removing your name and any specific identifiable information, assigning you an interviewee code to protect your anonymity and confidentiality. Further, some scenarios you discuss in detail in the interview may be summarized to generalize and protect your anonymity. The audiotape of my interview will be erased 6 months after completion of the dissertation.

Only the researcher, the Principal Investigator, the additional members of the dissertation committee, and transcriber will have access to the oral interview. All transcriptions and other data will be kept on a password protected computer and destroyed after 5 years.

Subject Assurances By signing this consent form, I agree to take part in this study. I have not given up any of my rights or released this institution from responsibility for carelessness.

I may cancel my consent and refuse to continue in this study at any time without penalty or loss of benefits. My relationship with the staff of the ICSW or the Sanville Institute for Clinical Social Work and Psychotherapy will not be affected in any way, now or in the future, if I refuse to take part, or if I begin the study and then withdraw.

204 If I have any questions about the research methods, I can contact Jennifer Bulow at (323) 823-4147 or Dr. Samoan Barish. at this phone number (310) 396-8274 If I have any questions about my rights – or my child’s rights – as a research subject, I may contact Dr. John Ridings, Chair of Institutional Review Board; ICSW; At Robert Morris Center, 401 South State Street; Suite 822, Chicago, IL 60605; irbchair@icsw.edu.

Signatures For the Subject I attest that I have been given a letter that explains the changes made to Jennifer Bulow’s IRB application. I have read and understand the contents of the letter. (must respond) Yes: _____ No: ______ I understand that I am reconsenting into this study under the auspices of the Institute for Clinical Social work and give full permission to Jennifer Bulow to use any data previously collected by her prior to her affiliation with the Institute for Clinical Social Work. (must respond) Yes: _____ No: ______ Would you like a summary of the results of this study?

Yes: _____ No: ______ I have read this consent form and I agree to take part in this study as it is explained in this consent form.

Participant Name: ____________________________________ Participant Signature: _________________________________ Date: _____________ For the Primary Researcher I certify that I have explained the research to _____________________ and believe that they understand and that they have agreed to participate freely. I agree to answer any additional questions when they arise during the research or afterward.

Researcher Name: ___________________________________ Researcher Signature: ________________________________ Date: _________

205

Appendix I: Interview Guide

206

Interview Guide 

Opening introduction: I am looking to better understand therapists respond to, work with, and conceptualize political material that emerges in psychotherapy sessions. I will be asking participants to elaborate on their personal and professional experiences, including detailed vignettes and clinical examples.



Review and sign informed consent and discuss protecting confidentiality and anonymity. Interviewees and any clients will be referred to by a pseudonym and all identifying information will be disguised. Acknowledge the personal nature of the interview and thank participant for willingness to be open.

1. Learn about the participant. Where were they trained? How long have they practiced and in what settings?

2. What does “political” mean to you? What do you consider “political”? What is your own relationship to politics and “the political”? How has this changed over time?

3. What do you consider to be “political” material in therapy? What are the different ways in which politics presents itself in the psychotherapy hour? When does this come up in therapy? Examples? How does “the political” come up in therapy? How/what do you observe your client’s responses to the political?

Examples?

4. How do you think about it in the session? And, outside of the session…

Examples?

5. How do you respond to it in the session? (Implicitly and explicitly) And, outside of the session… Examples?

6. What do you think about your responses to the political in session? Did you see any impact on the therapy relationship, on the client, and on you? If so, what…

7. What is your general position around self-disclosure? Do you use self-disclosure considering political material? If so, how? Has this evolved or changed over time?

What do you think about it? The impact of your choices? How do you feel about it? What have you noticed about it? Can you share some clinical experiences that exemplify your choices?

8. Do you see yourself sharing in an external political reality with clients? In what way does this come up in clinical work? If you acknowledge this, how so? Has this evolved or changed? How so…

207 9. In general, how do you think about politics and psychotherapy? Is there a place for politics in psychotherapy? If so, what might that look like, could you describe it and give some clinical examples.

10. Closing thoughts? What was it like to talk about this today? What has the discussion today brought up for you?

208

References

Alderman, L. (2016, October 20). Talking to your therapist about election anxiety. New York Times. New York.

Alexander, J. C. (2004). Toward a theory of cultural trauma. In J. C. Alexander, R. Eyerman, B. Giesen, N. J. Smelser, & P. Sztompka (Eds.), Cultural trauma and collective identity (p. 314). Berkeley: University of California Press.

Alexander, J. C., Eyerman, R., Giesen, B., Smelser, N. J., & Sztompka, P. (2004).

Cultural trauma and collective identity. Berkeley, Los Angeles, London: University of California Press.

Altman, N. (2010). The analyst in the inner city: Race, class, and culture through a psychoanalytic lens (Second Ed.). New York: Routledge.

American Psychological Association. (2017). Stress in America: The state of our nation stress in America TM Survey. https://www.apa.org/news/press/releases/stress/2017/state-nation.pdf Aristotle. (1963). Politics. In J. Somerville & R. E. Santoni (Eds.), Social and political philosophy, readings from Plato to Gandhi (p. 545 p.). Anchor Books.

Aron, L. (1991). The patient’s experience of the analyst’s subjectivity. Psychoanalytic Dialogues, 1(1), 29–51. https://doi.org/10.1080/10481889109538884 Aron, L. (1996a). Symposium on the meaning and practice of intersubjectivity in psychoanalysis. Psychoanalytic Dialogues, 6(5), 591–597.

209 Aron, L. (1996b). A meeting of minds: Mutuality in psychoanalysis. New Jersey: The Analytic Press.

Aron, L. (2005). On the unique contribution of the interpersonal approach to interaction: A discussion of Stephen A. Mitchell’s “Ideas of interaction in psychoanalysis.”

Contemporary Psychoanalysis, 41(1), 21–35.

Aron, L. (2006). Analytic impasse and the third: Clinical implications of intersubjectivity theory. International Journal of Psychoanalysis, 87, 349–368.

Aron, L., & Harris, A. (2010). Sándor Ferenczi: Discovery and rediscovery.

Psychoanalytic Perspectives, 7, 5–42.

Audet, C. T. (2011). Client perspectives of therapist self-disclosure: Violating boundaries or removing barriers? Counselling Psychology Quarterly, 24(2), 85–100. https://doi.org/10.1080/09515070.2011.589602 Audet, C. T., & Everall, R. D. (2010). Therapist self-disclosure and the therapeutic relationship: a phenomenological study from the client perspective. British Journal of Guidance & Counselling, 38(3), 327–342. https://doi.org/10.1080/03069885.2010.482450 Avissar, N. (2007). Politics and Israeli psychologists: Is it time to take a stand? Israel Journal of Psychiatry and Related Sciences, 44(1), 1–8.

Avissar, N. (2009). Clinical psychologists do politics: Attitudes and reactions of Israeli psychologists toward the political. Psychotherapy and Politics International, 7(3), 174–189. https://doi.org/10.1002/ppi Avissar, N. (2016). Psychotherapy, society, and politics. New York: Palgrave Macmillan. https://doi.org/10.1057/978-1-137-57597-5

210 Baum, N. (2010). Shared traumatic reality in communal disasters: Toward a conceptualization. Psychotherapy: Theory, Research, Practice, Training, 47(2), 249–259. https://doi.org/http://dx.doi.org/10.1037/a0019784 Baum, N. (2012). Trap of conflicting needs: Helping professionals in the wake of a shared traumatic reality. Clinical Social Work Journal, 40(37), 37045. https://doi.org/10.1007/s10615-011-0347-0 Baum, N. (2014). Professionals’ double exposure in the shared traumatic reality of wartime: Contributions to professional growth and stress. British Journal of Social Work, 44(8), 2113–2134. https://doi.org/http://dx.doi.org/10.1093/bjsw/bct085 Baum, N., & Dekel, R. (2010). Intervention in a shared traumatic reality: A new challenge for social workers. British Journal of Social Work, 40(6), 1927–1944. https://doi.org/10.1093/bjsw/bcp137 Bauwens, J., Glassman, M., & Tosone, C. (2014). The shared traumatic and professional posttraumatic growth inventory. Research on Social Work Practice, 1–9. https://doi.org/10.1177/1049731514549814 Bauwens, J., & Tosone, C. (2010). Professional posttraumatic growth after a shared traumatic experience : Manhattan clinicians’ perspectives on post-9 / 11 practice.

Journal of Loss and Trauma, 15(6), 498–517. https://doi.org/10.1080/15325024.2010.519267 Beebe, B., & Lachmann, F. (1988). The contribution of mother-infant mutual influence to the origins of self and object representations. Psychoanalytic Psychology, 5(4), 305– 337.

211 Beebe, B., & Lachmann, F. (2003). The relational turn in psychoanalysis. Contemporary Psychoanalysis, 39(3), 379–409. https://doi.org/10.1080/00107530.2003.10747213 Bendicsen, H. K., Koch, B. J., & Palombo, J. (2010). Guide to psychoanalytic developmental theories. New York: Springer. https://doi.org/10.1007/978-0-38788455-4 Benitez-Bloch, R. (2012). Integrating the internal and external worlds of clinical social work: A philosophical and political search. In E. B. Ruderman & C. Tosone (Eds.), Contemporary clinical practice: The holding environment under assault (pp. 29– 40). New York, NY: Springer New York. https://doi.org/10.1007/978-1-4614-41243_4 Benjamin, J. (1995). Recognition and Destruction: An outline of intersubjectivity. In Like subjects, love objects: Essays on recognition and sexual difference. New Haven: Yale University Press.

Benjamin, J. (1988). The bonds of love: Psychoanalysis, feminism, and the problem of domination. Pantheon Books.

Benjamin, J. (2017). “The Wolf’s Dictionary”: Confronting the triumph of a predatory world view. Contemporary Psychoanalysis, 53(4), 470–488. https://doi.org/10.1080/00107530.2017.1386043 Benyakar, M., Baruch, E., Kretsch, R., & Roth, M. (1997). A shared reality of therapists and survivors in a national crisis as illustrated by the Gulf War. Psychotherapy, 34(1), 28–33. https://doi.org/10.1037/h0087818

212 Berger, B. (2013). A perfect storm: The influence of outside forces on social work education. In E. Ruderman & C. Tosone (Eds.), Contemporary clinical practice: The holding environment under assault (pp. 61–72). New York: Springer.

Berman, E. (1997). Relational psychoanalysis: A historical background. American Journal of Psychotherapy, 51(2), 185–203.

Bernstein, J. W. (1999). The politics of self disclosure. Psychoanalytic Review, 86(4), 595–605.

Botticelli, S. (2004). The politics of relational psychoanalysis. Psychoanalytic Dialogues, 14(5), 635–651.

Brenner, G. H. (2017). Considering collective moral injury following the 2016 election.

Contemporary Psychoanalysis, 53(4) 547-560. https://doi.org/10.1080/00107530.2017.1384683 Bright, B. (September 6, 2017). Where politics, psyche, and community converge: An interview with Andrew Samuels. Pacifica Post. Pacifica Graduate Institute. https://www.youtube.com/watch?v=WI0c7hyy6pg Bromberg, P. M. (1994). Speak! That I may see you: Some reflections on dissociation, reality, and psychoanalytic listening. Psychoanalytic Dialogues, 4(4), 517–547.

Bromberg, P. M. (2009). Truth, human relatedness, and the analytic process: An interpersonal/relational perspective. International Journal of Psychoanalysis, 90, 347–361. https://doi.org/10.1111/j.1745-8315.2009.00137.x Bromberg, P. M. (2011). The shadow of the Tsunami and the growth of the relational mind. New York: Routledge.

213 Brunner, J. (2001). Freud and the politics of psychoanalysis. New Brunswick: Transaction.

Burnett-Zeigler, I. E. (2016, November 28). How Donald Trump affects therapy patients Time Magazine. Retrieved from http://time.com/4583628/donald-trump-therapypatients/ Busby, C. (2018). Personal communication.

Chodrow, N.J. (1989). Feminism and psychoanalytic theory. Yale University Press.

Chodorow, N. J. (2002). Born into a world at war: Listening for affect and personal meaning. American Imago, 59(3), 297–315.

Citizen Therapists for Democracy. Giving voice to our citizen and therapist voices.

(2017). Retrieved January 30, 2017, from http://citizentherapists.com/Contributors, Various. (n.d.). AAPCSW Google Groups Listserv. https://www.aapcsw.org/ Corbin, J. M., & Strauss, A. L. (2008). Basics of qualitative research: Techniques and procedures for developing grounded theory. Sage Publications.

Coren, S. (2018). Mr. Trump: How I learned to stop worrying and love the patientaggressor. Journal of Clinical Psychology, 74(5), 1–11. https://doi.org/https://doi.org/10.1002/jclp.22603 Cushman, P. (1995). Constructing the self, constructing America: a cultural history of psychotherapy. Perseus Pub. Cushman, P. (2015). Relational psychoanalysis as political resistance. Contemporary Psychoanalysis, 51(3), 423–459. https://doi.org/10.1080/00107530.2015.1056076 DeYoung, P. A. (2015). Relational psychotherapy: A primer (2nd ed.). New York: Routledge.

214 Dimen, M. (2006). Response to roundtable: Something’s gone missing. In L. Layton, N. C. Hollander, & S. Gutwill (Eds.), Psychoanalysis, class and politics: Encounters in the clinical setting (pp. 195–2001). New York: Routledge.

Ehrenberg, D. B. (1995). Self-disclosure: Therapeutic tool or indulgence?

Countertransference disclosure. Contemporary Psychoanalysis, 31(2), 213–228.

Ehrenberg, D. B. (2010). Working at the intimate edge. Contemporary Psychoanalysis, 46(1), 120–141.

Farber, B. A. (2006). Self-disclosure in psychotherapy. New York: Gilford Press.

Farber, B. A. (2018). “Clowns to the left of me, jokers to the right”: Politics and psychotherapy, 2018. Journal of Clinical Psychology, 74(5), 714–721. https://doi.org/10.1002/jclp.22600 Faust, D. S., Black, F. W., Abrahams, J. P., Warner, M. S., & Bellando, B. J. (2008). After the storm: Katrina’s impact on psychological practice in New Orleans. Professional Psychology: Research and Practice, 39(1), 1–6. https://doi.org/10.1037/07357028.39.1.1 Freud, S. (1912). Recommendations to physicians practising psycho-analysis. In J. Strachey (Ed.), The Standard Edition of the Complete Psycholgicalpsychological works of Sigmund Freud (Vol. 12), para. 18 (Vol. 12). London: Hogarth Press.

Freud, S., Riviere, J., & Stratchey, J. (1963). Civilization and its discontents (Hogarth Press). London.

Gay, P. (1989). Freud : a life for our time. New York: Anchor Books.

Geertz, C. (1973). Thick description: Toward and interpretive theory of culture. In The interpretation of cultures (pp. 3–30). Basic Books.

215 Glaser, B. G., & Strauss, A. L. (1967). The discovery of grounded theory: Strategies for qualitative research.

Greenberg, J. (2001). The analyst’s participation: A new look. Journal of the American Psychoanalytic Association, 49(2), 359–380.

Greenberg, J. R., & Mitchell, S. A. (1983). Object relations in psychoanalytic theory.

Cambridge, Massachusetts: Harvard University Press.

Gross, N. (December 16, 2016). Are Americans experiencing collective trauma? New York Times, Retrieved December 27, 2017 from https://www.nytimes.com/2016/12/16/opinion/sunday/are-americans-experiencingcollective-trauma.html?_=0 Guralnik, O. (2016). Sleeping dogs: Psychoanalysis and the socio-political.

Psychoanalytic Dialogues, 26(6), 655–663. https://doi.org/10.1080/10481885.2016.1235450 Guralnik, O. (2017a). Democrazy. Psychoanalytic Dialogues, 27(3), 363–364. https://doi.org/10.1080/10481885.2017.1310503 Guralnik, O. (2017b). The first 100 days: Elections on the couch. Psychoanalytic Activist. Retrieved April 23, 2017, from https://psychoanalyticactivist.com/2017/01/26/elections-on-the-couch/ Gutwill, S., & Hollander, N. C. (2006). Class and splitting in the clinical setting: the ideological dance in the transference and countertransference. In L. Layton, N. C. Hollander, & S. Gutwill (Eds.), Psychoanalysis, class and politics: Encounters in the clinical setting (pp. 92–106). New York: Routledge.

216 Hanisch, C. (2009). The Personal is political: The original feminist theory paper at the author’s web site. Retrieved December 23, 2017, from http://carolhanisch.org/CHwritings/PIP.html Harris, A. (2017a). Hidden in plain sight. Psychoanalytic Dialogues, 27(3), 377–378. https://doi.org/10.1080/10481885.2017.1310517 Harris, A. (2017b). Radioactive Identifications and the American Election: An Introduction. Psychoanalytic Dialogues, 27(3), 368–369. https://doi.org/10.1080/10481885.2017.1310510 Harris, A., & Suchet, M. (2002). Book Review of Stephen A. Mitchell’s Relationality: From attachment to intersubjectivity. American Imago (Vol. 59). https://doi.org/10.1037//0736-9735.18.3.582 Henretty, J. R., & Levitt, H. M. (2010). The role of therapist self-disclosure in psychotherapy: A qualitative review. Clinical Psychology Review. https://doi.org/10.1016/j.cpr.2009.09.004 Herman, J. L., & Lifton, R. J. (2017, March 8). “Protect us from this dangerous President,” 2 psychiatrists say. New York Times. New York.

Hill, C. E., & Knox, S. (2001). Self-disclosure. Psychotherapy, 38(4), 413–417.

Hill, C. E., & Knox, S. (2003). Therapist self disclosure: Research-based suggestions for practitioners. Journal of Clinical Psychology/In Session, 59(5), 529–539.

Hill, D. (2015). Affect regulation theory: A clinical model. W.W. Norton and Co. Hill, M., & Ballou, M. (1998). Making therapy feminist: A practice survey. Women & Therapy, 21(2), 1–11.

217 Hoffman, I. Z. (1983). The Patient as interpreter of the analyst’s experience.

Contemporary Psychoanalysis, 19, 389–422.

Hopenwasser, K. (2017). Collective trauma and communal affect regulation. Retrieved October 7, 2017, from http://csar.nyc/collective-trauma-and-communal-affectregulation/ Kantrowitz, J. L. (1996). The patient’s impact on the analyst. Analytic Press.

Karlamangla, S. (2017, February 24). Why therapists are having such a hard time talking about Trump. Los Angeles Times. Los Angeles.

Keinan-Kon, N. (1998). Internal reality, external reality, and denial in the Gulf War. Journal of the American Academy of Psychoanalysis , 26(3), 417–442.

Khouri, L. Z. (2017). She, Trump, and I. Psychoanalytic Dialogues, 27(3), 383–384. https://doi.org/10.1080/10481885.2017.1310528 Lachmann, F., M. (2004). Identity and self: Historical antecedents and developmental precursors. International Forum of Psychoanalysis, 13(4), 246–253.

Layton, L. (2006). Attacks on linking: The unconscious pull to dissociate individuals from their social context. In L. Layton, N. C. Hollander, & S. Gutwill (Eds.), Psychoanalysis, class and politics: Encounters in the clinical setting (pp. 107–117).

New York: Routledge.

Layton, L., Hollander, N. C., & Gutwill, S. (Eds.). (2006). Is politics the last taboo in psychoanalysis: A roundtable discussion with Neil Altman, Jessica Benjamin, Ted Jacobs, and Paul Wachtel. Moderated by Amanda Hirsch Geffner. In Psychoanalysis, class and politics: Encounters in the clinical setting (pp. 166–194).

New York: Routledge.

218 Layton, L., Hollander, N. C., & Gutwill, S. (Eds.). (2006). Psychoanalysis, class and politics : encounters in the clinical setting. Routledge.

Lee, B. X. (Ed.). (2017). The dangerous case of Donald Trump : 27 psychiatrists and mental health experts assess a president. New York: Thomas Dunne Books.

Lyford, C. (2017). Therapy in post-election America. Psychotherapy Networker.

Retrieved April 23, 2017, from https://www.psychotherapynetworker.org/blog/details/1124/therapy-in-post-electionamerica Maroda, K. J. (1999). Creating an intersubjective context for self-disclosure. Smith College Studies in Social Work, 69(2), 474–489.

Matthews, J. R. (2007). A Louisiana psychologist’s experience with Hurricanes Katrina and Rita. Psychological Services, 4(4), 323–328. https://doi.org/10.1037/15411559.4.4.323 Merriam-Webster. (2017). Definition of Politics by Merriam-Webster. Retrieved May 17, 2017, from https://www.merriam-webster.com/dictionary/politics Miller, F. (1998). Aristotle’s Political Theory. https://doi.org/10.1515/apeiron.1989.22.4.195 Milton, M., & Legg, C. (2000). Politics in psychotherapy: Therapists’ responses to political material. Counselling Psychology Quarterly, 13(3), 279–291. https://doi.org/10.1080/09515070010002604 Mishler, E. G. (1986). Research interviewing: Context and narrative. Harvard University Press.

219 Mitchell, S. A., & Harris, A. (2004). What’s American about American psychoanalysis?

Psychoanalytic Dialogues, 14(2), 165–191.

Mitchell, S. A. (1988). Relational concepts in psychoanalysis: An integration. Harvard University Press.

Mitchell, S. A. (1993). Hope and dread in psychoanalysis. New York: Basic Books.

Mitchell, S. A., & Black, M. J. (1995). Freud and beyond: A history of modern psychoanalytic thought. New York: Basic Books.

Modell, A. H. (1989). The psychoanalytic setting as a container of multiple levels of reality: A perspective on the theory of psychoanalytic treatment. Psychoanalytic Inquiry, 9(1), 67–87. https://doi.org/10.1080/07351698909533755 Modell, A. H. (1991). The therapeutic relationship as a paradoxical experience.

Psychoanalytic Dialogues, 1(1), 13–28. https://doi.org/10.1080/10481889109538883 Modell, A. H. (2009). Metaphor - the bridge between feelings and knowledge.

Psychoanalytic Inquiry, 29(1), 6–11. https://doi.org/10.1080/07351690802246890 Murdach, A. D. (2010). Does American Social Work Have a Progressive Tradition?

Social Work, 55(1).

NASW-CA Chapter. (2017). NASW-CA Chapter Facebook page. Retrieved December 13, 2017, from https://www.facebook.com/naswca/ Neal, A. G. (1998). National trauma and collective memory: Major events in the American century. Armonk, NY: M.E. Sharpe. https://doi.org/10.2307/2655021

220 Nunberg, H., Dahl, K., Herschkowitz, S., Kantrowitz, L., J., Neubauer, P., Orgel, S., Fogelman, E. (2011). Psychoanalytic reflections through the prism of September 11, 2001. Psychoanalytic Study of the Child, 65, 313–331.

Ogden, T. (1997). Reverie and metaphor. Some thoughts on how I work as a psychoanalyst. The International Journal of Psycho-Analysis, 78, 719–32.

Ogden, T. H. (2004). The analytic third: Implications for psychoanalytic theory and technique. The Psychoanalytic Quarterly, 73(1), 167–195. https://doi.org/10.1002/j.2167-4086.2004.tb00156.x Orbach, S. (2018, January). Misogyny on the couch: why it’s time to let psychoanalysis into politics. Prospect: The Leading Magazine of Ideas.

Orlinsky, D. E., & Rønnestad, M. H. (2005). How psychotherapists develop: A study of therapeutic work and professional growth. Washington: American Psychological Association. https://doi.org/10.1037/11157-000 Ornstein, E. D., & Ganzer, C. (2005). Relational social work: A model for the future.

Families in Society, 86(4), 565–572.

Ornstein, E. D., & Ganzer, C. (1997). Mitchell’s relational conflict model: An analysis of its usefulness in clinical social work. Clinical Social Work Journal, 25(4), 391–405.

Panning, J. C. (2017). Trump anxiety disorder: The Trump effect on the mental health of half the nation and special populations. In B. X. Lee (Ed.), The dangerous case of Donald Trump: 27 psychiatrists and mental health experts assess a president (pp.

235–243). New York: Thomas Dunne Books.

Patton, M. (1990). Designing Qualitative Studies. In Qualitative evaluation and research methods (pp. 169–186). Beverly Hills: Sage.

221 Perlman, F., & Frankel, J. (2009). Relational psychoanalysis: A review. Psychoanalytic Social Work, 16, 105–125.

Petrucelli, J. (2017). Introduction: “Making America ‘HUGE’; again”: Mindfulness (or the people) vs. Donald Trump. Contemporary Psychoanalysis, 53(4), 447–453. https://doi.org/10.1080/00107530.2017.1384667 Philipson, I. (2018). “I should like to point out that there is an air-raid going on outside!”: Psychoanalysis and the denial of the analyst’s trauma. Psychoanalytic Perspectives, 15(1), 38–47. https://doi.org/10.1080/1551806X.2018.1396126 Porges, S. W. (2009). The polyvagal theory: new insights into adaptive reactions of the autonomic nervous system. Cleveland Clinic Journal of Medicine, 76(Suppl 2), S8690. https://doi.org/10.3949/ccjm.76.s2.17 Porges, S. W. (2011). The polyvagal theory: Neurophysiological foundations of emotions, attachment, communication, and self-regulation. New York: W.W. Norton & Company.

Porges, S. W. (2017). The pocket guide to the polyvagal theory: The transformative power of feeling safe. New York: W.W. Norton & Company.

Ramos, C., & Leal, I. (2013). Posttraumatic growth in the aftermath of trauma: A literature review about related factors and application contexts. Psychology, Community & Health, 2(1), 43–54. https://doi.org/10.5964/pch.v2i1.39 Raskin, P. M. (2018). “She’s woke”: The paradoxical effects of the 2016 election on an individual client. Journal of Clinical Psychology, 74(5), 1–9. https://doi.org/https://doi.org/10.1002/jclp.22604

222 Redding, K. K. (2008). Book review of L. Layton, N. C. Hollander, S. Gutwill, psychoanalysis, class, and politics : Encounters in the clinical setting. Clinical Social Work Journal, 36, 317–319. https://doi.org/10.1007/s10615-008-0161-5 Renik, O. (1999). Playing one’s cards face up in analysis: An approach to the problem of self-disclosure. Psychoanalytic Quarterly, 68(4), 521–539. https://doi.org/10.1002/j.2167-4086.1999.tb00546.x Ringel, S. (2002). To disclose or not to disclose political conflicts in the countertransference. Smith College Studies in Social Work, 72(3), 347–358.

Ringstrom, P. A. (2010). Meeting Mitchell’s challenge: A comparison of relational psychoanalysis and intersubjective systems theory. Psychoanalytic Dialogues, 20, 196–218.

Rosenfield, K. (2017). We’ve come undone: Shape shifting the frame after the 2016 U.S. election. Psychoanalytic Dialogues, 27(3), 370–371. https://doi.org/10.1080/10481885.2017.1310511 Rosenwald, M. (2006). Exploring the political diversity of social workers. Social Work Research, 30(2).

Rosenwald, M., & Hyde, C. A. (2006). Political Ideologies in Social Work. Advances of Social Work, 7(2), 12–22.

Rozmarin, E. (2017a). The day after in therapy. Psychoanalytic Dialogues, 27(2), 119– 121. https://doi.org/10.1080/10481885.2017.1286150 Rozmarin, E. (2017b). The Social is the Unconscious of the Unconscious of Psychoanalysis. Contemporary Psychoanalysis, 53(4), 459–469. https://doi.org/10.1080/00107530.2017.1385373

223 Ruderman, E. G. (2008). The impact of the outside world — War, politics, environment and health care: A dilemma for clinical practice. Clinical Social Work Journal, 36(2), 207–209. https://doi.org/10.1007/s10615-008-0154-4 Ruderman, E. (2012). The world outside: Its impact on the treatment setting. In E. B. Ruderman & C. Tosone (Eds.), Contemporary clinical practice: The holding environment under assault (pp. 1–11). New York, NY: Springer New York. https://doi.org/10.1007/978-1-4614-4124-3_1 Ruderman, E., & Tosone, C. (Eds.). (2013). Contemporary clinical practice: The holding environment under assault. New York, NY: Springer.

Sadighim, S. (2014). The big reveal: Ethical implications of therapist self disclosure.

Psychotherapy Bulletin, 49(4), 22–27.

Samuels, A. (1992). Countertransference and politics. British Journal of Psychotherapy, 9(1), 40–63.

Samuels, A. (1993). The political psyche. Routledge.

Samuels, A. (2001). Politics on the couch: Citizenship and the internal life. New York: Other Press.

Samuels, A. (2004). Politics on the couch? Psychotherapy and society - Some possibilities and some limitations. Psychoanalytic Dialogues, 14(6), 817–834.

Samuels, A. (2006). Working directly with political, social and cultural material in the therapy session. In L. Layton, N. C. Hollander, & S. Gutwill (Eds.), Psychoanalysis, class and politics: Encounters in the clinical setting (Routledge, pp. 11–28). New York.

224 Samuels, A. (2014). Political and clinical developments in analytical psychology, 19722014: Subjectivity, equality and diversity - inside and outside the consulting room.

Journal of Analytical Psychology, 59(5), 641–660. https://doi.org/10.1111/14685922.12115 Samuels, A. (2015). A new therapy for politics? London: Karnac Books.

Samuels, A. (October 2017). The rationality of political violence: “Our” fascination and envy of “Them.” Lecture at C.G. Jung Institute of Los Angeles Public Programs: Fall 2017.

Samuels, A. (2017). Forward. In R. Tweedy (Ed.), The political self: Understanding the social context for mental illness: (pp. xvii–xxiii). London: Karnac Books.

Sandberg, L. S. (2017). Shame and the question of responsibility. Psychoanalytic Dialogues, 27(3), 382–383. https://doi.org/10.1080/10481885.2017.1310526 Sanville, J. B. (1997). Philosophical considerations in analysis. Clinical Social Work Journal, 25(1), 19–25.

Schamess, G. (2012). Mutual transformation in psychotherapy. Clinical Social Work Journal, 40(1), 10–22. https://doi.org/10.1007/s10615-011-0349-y Schmideberg, M. (1942). Some observations on individual reactions to air raids.

International Journal of Psycho-Analysis, 23, 146–176.

Schore, A. N. (2003a). Affect regulation and the repair of the self (1st ed.). W.W. Norton & Company.

Schore, A. N. (2003b). Affect dysregulation and disorders of the self. W.W. Norton & Company.

225 Schore, A. (2011a). Forward. In The shadow of the Tsunami and the growth of the relational mind (pp. ix–xxxvii). New York: Routledge.

Schore, A. N. (2011b). The right brain implicit self lies at the core of psychoanalysis.

Psychoanalytic Dialogues, 21, 75–100. https://doi.org/10.1080/10481885.2011.545329 Schore, A. N. (2012). The Science of the art of psychotherapy. W.W. Norton & Company.

Schore, J. R., & Schore, A. N. (2008). Modern attachment theory: The central role of affect regulation in development and treatment. Clinical Social Work Journal, 36(1), 9–20. https://doi.org/10.1007/s10615-007-0111-7 Section IX, APA Psychoanalysts for Social Responsibility, Division of Psychoanalysis, (April 6, 2017). First 100 days: Can psychoanalysis help us to overcome paranoid politics? The Psychoanalytic Activist. Retrieved June 17, 2017, from https://psychoanalyticactivist.com/2017/04/06/first-100-days-can-psychoanalysishelp-us-to-overcome-paranoid-politics/ Seeley, K. (2005). Trauma as a metaphor: the politics of psychotherapy after September 11. Psychotherapy and Politics International, 3(1), 17–27. https://doi.org/10.1002/ppi.14 Segal, E. (2013). Beyond the pale of psychoanalysis: Relational theory and generalist social work practice. Clinical Social Work Journal, 41(4), 376–386. https://doi.org/10.1007/s10615-012-0415-0 Seligman, S., Ipp, H., & Bass, A. (2017). Working in the shadow of the election: The day after at work in the aftermath of the Trump victory: Editors’ introduction.

226 Psychoanalytic Dialogues, 27(2), 111–112. https://doi.org/10.1080/10481885.2017.1286170 Shedler, J. (2010). The efficacy of psychodynamic psychotherapy. American Psychologist, 65(2), 98–109. https://doi.org/10.1037/a0018378 Siebold, C. (2011). What do patients want?: Personal disclosure and the intersubjective perspective. Clinical Social Work Journal, 39(2), 151–160. https://doi.org/10.1007/s10615-011-0338-1 Slavin, M. O. (2017). Strangers in our own land: Searching for meaning and vision on the cusp of Trump’s America. Psychoanalytic Dialogues, 27(3), 354–358. https://doi.org/10.1080/10481885.2017.1308217 Smelser, N. J. (2004). Psychological trauma and cultural trauma. In J. C. Alexander, R. Eyerman, B. Giesen, N. J. Smelser, & P. Sztompka (Eds.), Cultural Trauma and Collective Identity (p. 314). University of California Press.

Solomonov, N., & Barber, J. P. (2018). Patients’ perspectives on political self-disclosure, the therapeutic alliance, and the infiltration of politics into the therapy room in the Trump era. Journal of Clinical Psychology, 74(5), 779–787. https://doi.org/10.1002/jclp.22609 Spielberg, W. (2017). A tale of two firefighters and Trump. Psychoanalytic Dialogues, 27(3), 366–368. https://doi.org/10.1080/10481885.2017.1310508 Stern, D. N. (1985). The interpersonal world of the infant: A view from psychoanalysis and developmental psychology. New York: Basic Books.

Stolorow, R. D., & Atwood, G. E. (1993). Faces in a cloud: Intersubjectivity in personality theory. New Jersey: Aronson.

227 Stolorow, R. D., & Atwood, G. E. (1996). The intersubjective perspective. The Psychoanalytic Review, 83, 181–194.

Stolorow, R. D., & Atwood, G. E. (2002). Contexts of being: The intersubjective foundations of psychological life. (Reprinted). New York: Psychology Press.

Strozier, C. B. (2017). Those who live by the sword. Contemporary Psychoanalysis, 53(4), 454–458. https://doi.org/10.1080/00107530.2017.1381907 Suchet, M. (2007). Unraveling whiteness. Psychoanalytic Dialogues, 17(6), 867–886. https://doi.org/10.1080/10481880701703730 Sweezy, M. (2005). Not confidential: Therapist considerations in self-disclosure. Smith College Studies in Social Work, 75(1), 81–91. https://doi.org/10.1300/J497v75n01 Tedeschi, R. G., & Calhoun, L. (2004a). Posttraumatic growth: A new perspective on psychotraumatology. Psychiatric Times, 21(4), 58–59.

Tedeschi, R. G., & Calhoun, L. G. (2004b). Posttraumatic growth: Conceptual foundations and empirical evidence. Psychological Inquiry, 15(1), 1–18. https://doi.org/10.1207/s15327965pli1501_01 Tolleson, J. (2012). Saving the world one patient at a time: psychoanalysis and social critique. In E. B. Ruderman & C. Tosone (Eds.), Contemporary clinical practice: The holding environment under assault (pp. 99–115). New York, NY: Springer New York. https://doi.org/10.1007/978-1-4614-4124-3_10 Tosone, C. (2004). Relational social work: Honoring the tradition. Smith College Studies in Social Work, 74(3), 475–487.

Tosone, C. (2006). Therapeutic intimacy: A Post-9 / 11 perspective. Smith College Studies in Social Work, 76(4), 89.

228 Tosone, C. (2011). The legacy of September 11: Shared trauma, therapeutic intimacy, and professional posttraumatic growth. Traumatology, 17(3), 25–29. https://doi.org/10.1177/1534765611421963 Tosone, C., McTighe, J. P., Bauwens, J., & Naturale, A. (2011). Shared traumatic stress and the long-term impact of 9/11 on Manhattan clinicians. Journal of Traumatic Stress, 24(5), 546–552. https://doi.org/10.1002/jts.20686 Tosone, C., Nuttman-Shwartz, O., & Stephens, T. (2012). Shared trauma: When the professional is personal. Clinical Social Work Journal, 40(2), 231–239. https://doi.org/10.1007/s10615-012-0395-0 Tosone, C., McTighe, J. P., & Bauwens, J. (2015). Shared traumatic stress among social workers in the aftermath of Hurricane Katrina. British Journal of Social Work, 45(4), 1313–1329. https://doi.org/10.1093/bjsw/bct194 Totton, N. (2000). Psychotherapy and politics. London: Sage Publications.

Totton, N. (2008). The politics of psychotherapy. Psychotherapy and Politics International, 6(2), 82–90. https://doi.org/10.1002/ppi.164 Tweedy, R. (Ed.). (2017). The political self: Understanding the social context for mental illness. London: Karnac Books.

Violette, B. L. (2012). Silence in the clinical hour: A time to speak. In E. B. Ruderman & C. Tosone (Eds.), Contemporary clinical practice: The holding environment under assault (pp. 73–83). New York, NY: Springer New York. https://doi.org/10.1007/978-1-4614-4124-3_8 Wachtel, P. L. (2011). Therapeutic communication: Knowing what to say when (Second Edi). New York: Gilford Press.

229 Wachtel, P. L. (2017). The relationality of everyday life: The unfinished journey of relational psychoanalysis. Psychoanalytic Dialogues, 27(5), 503–521. https://doi.org/10.1080/10481885.2017.1355673 Wilson, M. (2017). The fragility of the frame. Psychoanalytic Dialogues, 27(3), 361–362. https://doi.org/10.1080/10481885.2017.1310500 Wineburgh, A. L. (2013). Mutual transformation. Clinical Social Work Journal, 41(4), 366–375. https://doi.org/10.1007/s10615-012-0413-2 Wyatt, R. C., & Yalom, V. (2008). Owen Renik on practical psychoanalysis and psychotherapy. Retrieved December 23, 2017, from https://www.psychotherapy.net/interview/owen-renik Yourman, D. B. (2018). A Marxist therapist treats a Trump-supporting client: A tale of politics and psychotherapy. Journal of Clinical Psychology, 74(5), 1–27. https://doi.org/10.1002/pssb.201300062