Next Level Practitioner

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1 Next Level Practitioner - Abandonment Week 132, Day 5 - Critical Insights - Transcript - pg. 1 Next Level Practitioner Week 132: Strategies for Clients Who Fear Abandonment Day 5: Critical Insights with Ron Siegel, PsyD; Kelly McGonigal, PhD; and Ruth Buczynski, PhD

2 Next Level Practitioner - Abandonment Week 132, Day 5 - Critical Insights - Transcript - pg. 2 Week 132, Day 5: Ron Siegel, PsyD and Kelly McGonigal, PhD Critical Insights Table of Contents (click to go to a page) The Importance of Comfort in a Therapeutic Setting... 3 How to Find Connection Outside of Interpersonal Relationships... 4 When It s Appropriate to Use Touch with Clients... 4 Research on How Low-Intensity Touch Can Revolutionize Work with Clients... 6 How Different Styles of Attachment Effect Abandonment Issues... 7 New Research on Yoga and PTSD... 8

3 Next Level Practitioner - Abandonment Week 132, Day 5 - Critical Insights - Transcript - pg. 3 Week 132, Day 5: Ron Siegel, PsyD and Kelly McGonigal, PhD Critical Insights Dr. Buczynski: Hello everyone. We re back. This is the part of the week where we re going to conceptualize some of the ideas that you ve heard this week. We re on a new question: Working with people who feel abandoned. I m joined, as I always am, by my two good buddies, Drs. Ron Siegel and Kelly McGonigal. I m going to start with the same question that we always do, which is what stood out to you this week? How about, Ron, we ll start with you, and then we ll go to you, Kelly, and then I ll have some specific questions after that. The Importance of Comfort in a Therapeutic Setting Dr. Siegel: This is going to be a great topic. What stood out most was that most of our contributors emphasized the need to establish a sense of safety, and really to provide in the therapy soothing and safe social connection for people with abandonment fears. They didn t actually address the other side of this, which is how we might help a patient or client to sit with and be with the distress over abandonment. It was much more they moved in the direction of how to comfort them first. This fits my clinical experience, certainly: that you want to start by creating a safe therapeutic alliance, and part of that involves helping people to feel like we re not going to abandon them. They used an interesting variety of approaches: Bessel was talking about using yoga, and neural feedback, and other related methods to try to calm the person as a way of establishing safety. Our contributors emphasized the need to provide in the therapy soothing and safe social connection for people with abandonment fears. Shelly talked about using the comfort of music and a very interesting take on this: the sense that music connects us to others, in a sense. I think of singing the Blues as an example of that, so that you re not alone with your pain. Deb talked about what in psychodynamic terms we would always call transitional objects using a quotation card, or a voice recording that the person could carry with them, as well as physical touch like a handshake, or perhaps more a hand on You want to start by the back. creating a safe therapeutic alliance, and part of that involves helping people to feel like we re not going to abandon them. Bonnie talked about the need for consistency as well as providing props. She mentioned a wonderful moment in which a client was feeling in need; it felt like, Oh, I wish I had some blankets here, and she went out and got blankets that kind of thing. Perhaps later in the series we ll talk about the other side of this, which is once a person has the comfort zone well established and does feel a sense of trust and safety, is there a role for illuminating and learning to stay with the fears of abandonment?

4 Next Level Practitioner - Abandonment Week 132, Day 5 - Critical Insights - Transcript - pg. 4 Of course, in the old days, psychoanalysts did this over the top: sitting behind the patient and not saying anything, and mysteriously everybody felt like they were about to be abandoned and they needed more love. That was a setup from the situation, and we don t want to do that, but it still has its uses. There s a role for mindfulness practice also in helping people to stay with simply the sensations and the longing to not be abandoned. But I m sure we ll get into that later. Dr. Buczynski: How about you, Kelly what stood out to you this week? How to Find Connection Outside of Interpersonal Relationships Dr. McGonigal: First, I just want to comment on something that Ron said: that it s surprising how music can be used for this social connection. It reminded me of research: musicologists have found that listening to music is inherently social and activates the social brain in part because when we listen to music, our brains immediately try to understand how it was produced, and it activates your broad spots of the mirror-neuron system. So you re trying to understand how the sounds were created and also why they were created, and so any kind of emotional content provokes very strong empathic responses. That leads people to feel very connected to the people who have produced the music. Dr. Siegel: That s very interesting. Dr. McGonigal: Yes. It s one of the reasons why people who often are depressed will turn to music as a first kind of safe social connection. Musicologists have found that listening to music is inherently social and activates the social brain. I also love this idea of transformed reconnection. I never heard that phrase used before, but Shelly mentioned that sometimes you need to find these other ways of experiencing connection that might not be with humans, and the idea of Sometimes you need to music was one. But I m thinking about all the other types of connection find these other ways of that can be really meaningful, just with nonhumans: animals; with nature; through prayer. experiencing connection that might not be with humans, and the idea of music was one. I love this idea that people who are having issues around attachment, or abandonment, or safety, and in human relationships could turn toward other aspects of connection that are just as important and can be very healing. I also wanted to mention specifically and Ron you mentioned this too Deb s practice of using cards to help people stay connected between sessions. That stood out to me. Again, I hadn t heard of or seen someone doing that, and I really appreciated that as a concrete example. When It s Appropriate to Use Touch with Clients Dr. Buczynski: Thanks, Kelly. The first question that I d like to ask, I d actually like to ask both of you. Let me dive in: Deb Dana talked about how touch can help regulate a person s nervous system, and she talked about a handshake or a hand on the middle of the back as examples of that.

5 Next Level Practitioner - Abandonment Week 132, Day 5 - Critical Insights - Transcript - pg. 5 What I d like to ask is what s the research showing about types of touch that can soothe when someone is distressed? How about if we start with you, Ron, then we ll go to you, Kelly? Dr. Siegel: Now, I don t actually know the research literature very well; I suspect Kelly s going to be able to fill this in/fill us in more on that although it would seem, at face value, that, given how powerful touch is to all of us subjectively, it wouldn t be that hard to measure some of its effects. But actually, your question brings to mind something else, because I was actually quite moved when Deb was talking about this, and we ve talked before in this series about perhaps gender differences that can come up among therapists in terms of comfort in different situations. We talked about how, as a man, I might be a little bit more predisposed to go a little further in a situation that felt unsafe in some ways than a woman therapist might. Kelly had talked some about that, in the educator role. But we re all so different around touch. I realize that, in my personal life, I m very comfortable with hugging, and closeness, and certainly shaking hands, as well as cuddling, and I m reasonably comfortable with sexuality and all sorts of aspects of touch. But professionally, I m ultra-conservative and I m not ultra-conservative in many parts of my life, but I m very afraid that I might touch somebody in a way that wouldn t feel comfortable to them and that if it didn t feel comfortable to them, it could be big trouble for both of us. Because when touch feels uncomfortable, very often it feels sexualized to people, and the thought that somebody would no longer feel safe with me because they felt that I was being sexualized is very injurious to the relationship. The scariest thing I can think of, seriously, as a therapist, is, having to defend myself against some kind of accusation of sexual impropriety. We talked a lot about shame earlier in the series; I m imagining that shame would be like over the top for me. When touch feels uncomfortable, very often it feels sexualized to people. Gender differences can come up among therapists in terms of comfort in different situations, but we re all so different around touch. So it s very interesting here. I was once talking to a colleague who did talks on professional ethics, and one of her colleagues said to her, Really? You do a whole workshop on professional ethics? Isn t it two rules: don t have sex with your clients, and don t have them mow your lawn? Those rules have always seemed to be pretty good to follow. I realize that, in a certain way, I m always paranoid around this in a way that it struck me as sad when Deb was talking about that. If a client asked me for a hug at the end of a session, if they ask and it s like the last session of therapy, yes, but I signal that, Hmm, that s not going to be part of our interaction, during the rest of our work. I ve seen Peter Levine work sometimes and say, Would it be okay with you if I put my foot near your foot? when they re sitting kind of cattycorner, as a way to have something approximating touch. But beyond that, it s just too dangerous as a man. I wonder what your thought is, as a woman therapist, or Kelly s as a woman educator, whether it s different and whether you re less worried than I would be? Dr. Buczynski: I m pretty cautious. I mean, I don t think I was as cautious when I first started practicing, in the late seventies, but then sometime by the late eighties and onward, I ve been pretty cautious. Over time, ideas have shifted about a lot of things, and, yes, I m pretty careful.

6 Next Level Practitioner - Abandonment Week 132, Day 5 - Critical Insights - Transcript - pg. 6 Dr. Siegel: Yes, I mean, it seems sad in the sense, given how powerful it is as a means. That s what I was struck by from Deb: how powerful of course it s so/such a powerful way of communicating, and yet it s like, Ew It s dangerous. Dr. Buczynski: I will say, Ron, that I would often put my hand on the back of a person s back as they re leaving; sort of in the middle on the back, just, and say, Call me if you need me, or something like that. That s my sendout. But no, probably not otherwise. Kelly, what about you as far as Ron s question? Then we ll get to you. I notice a difference with the younger generation; they understand consent, and have boundaries around their bodies that they re Dr. McGonigal: Yes, when people ask for a hug or offer a hug, I m happy to reciprocate as a teacher in a teacher role, or in a speaking comfortable expressing. or author role. But I notice a difference with the younger generation; they understand consent, and many people have boundaries around their bodies that they re comfortable expressing and don t want violated there. It s one of the things that I m trying to be sensitive to also. There are many communities I ve participated in where touch was considered a major part of what was happening like in the yoga community - that s changed a lot in the last decade too. Ron, I appreciate your conservatism around that, and also sharing the kind of sadness that people have such a touch deficit, but the therapeutic relationship may not be the place to restore that deficit because of issues of power and vulnerability. Research on How Low-Intensity Touch Can Revolutionize Work with Clients Dr. McGonigal: But speaking of the research, I ll share some research that actually looks at the benefits of soothing touch that is not about receiving, that may be like self-soothing. I actually am going to send you a 2015 review paper that I found really interesting, that was looking at Low-intensity touch can how different types of what they call low-intensity touch: how lowintensity touch can reliably increase the release of oxytocin in a way reliably increase the release that helps regulate stress and increase feelings of social safety and connection. of oxytocin in a way that helps regulate stress and increase feelings of social safety and connection. I m going to mention one type of study that they looked at, which could have some misleading conclusions, but I thought it was so fascinating, so I m going to put it in a very careful framework. They looked at animal research where they delivered low-intensity touch while animals were unconscious, and they found that it had the same effect as when touch was delivered when animals were conscious. The big framework I m putting around this is I m not talking about non-consensual human touch, or touching people when they re asleep I m not saying you should do this. But what was really interesting is these studies suggest that there is something that is literally about the tactile stimulation that s not mediated by the psychological interpretation of the touch; that you can literally be unconscious and if certain receptors in your skin and connective tissue are depressed or deformed in a way that one might associate with stroking or massage, that it has these physiological effects.

7 Next Level Practitioner - Abandonment Week 132, Day 5 - Critical Insights - Transcript - pg. 7 Please don t misinterpret that as anything weird with humans; this is, literally, a physiological reflex, so some of the things that were in this review paper I thought were really relevant. One is that the chest seemed to be particularly sensitive to the psychological and social benefits of soothing touch that might be related to how you have to hold an infant to your chest, or even breastfeeding. It reminded me of Kristin Neff and Chris Germer they often talk about self-soothing touch and compassionate touch, and one of the gestures they often refer to is putting a hand on your chest. It s just interesting to think that actually the preceptors around the skin on your chest might be particularly receptive and sensitive to soothing touch, and that may be one The same levels of reason why it s so effective. oxytocin released on the The other thing that was interesting in this review to me is that when person giving the massage you touch someone else in this manner, it has the same effect as as the person receiving it. when you re being touched. So they looked at, for example, people giving a massage, and the same levels of oxytocin released on the person giving the massage as the person receiving it. They also mentioned research where maternal depression can be reduced by massaging the infant. This suggests that another thing that you could encourage people to do because you re not touching them yourself is to look for ways to incorporate intentional touch in their own lives, with their children or their pets, or receiving a massage in a sort of safe and contained way. Dr. Siegel: Yes. That s very interesting. It actually reminds me and maybe this was touched on in the review article but I read at one point that people had identified that a certain speed or frequency of stroking, directly at the level of the skin, transmits signals that we pick up with the brain, and if you varied the speed too much outside of this optimal window, it doesn t show up in the brain. There is something about the tactile stimulation that s not mediated by the psychological interpretation of the touch. You could encourage people to look for ways to incorporate intentional touch in their own lives, with their children or pets. Dr. McGonigal: I ve seen that. I don't think that was in this review paper, but also things like temperature: slight warmth is better than other temperatures. Also, in humans (we ve mentioned this/maybe I ve mentioned this before), who you think is delivering the touch matters quite a bit. If you have positive feelings toward the person delivering it, the brain actually interprets it differently than when it s a neutral or aversive person. How Different Styles of Attachment Effect Abandonment Issues Dr. Buczynski: Thanks. The next question I d like to ask, I d actually like to come at this from a different perspective now and, Ron, this is for you. Bonnie Goldstein talked about clients who, as a defense against being abandoned, decide to abandon others. Essentially they re preempting any possibility of getting abandoned by their instinct to cut and run. How do you work with that kind of person? Dr. Siegel: Yes, I was grateful to her for bringing this up, because it s very important. I tend to think of this as she did, in terms of varied attachment styles and therefore different reactions to abandonment based on the different attachment styles.

8 Next Level Practitioner - Abandonment Week 132, Day 5 - Critical Insights - Transcript - pg. 8 This is a very important question. Bonnie brought it up in the context of various attachment styles. Considering different attachment styles is certainly one of the There are some people who more important things we need to do as therapists, because if we have a different attachment style, we re going to have very need time alone to recharge. different reactions to abandonment. Whereas there are other people who as soon as they don t see where they re going to be with another person shortly, they start to feel very uneasy and start to have a lot of fears of abandonment. There are some people who need time alone to recharge. They need to be by themselves; they need to go out in nature; they need to be away from the stressors of interpersonal contact. Whereas there are other people who as Bonnie put it as soon as they don t have another date on their calendar or they don t see where they re going to be with another person shortly, they start to feel very uneasy and start to have a lot of fears of abandonment. I ve had patients of both sorts over the years. I ve had some who were on the more skittish side, and what comes to mind is The Grateful Dead line that says, You told me goodbye, How was I to know, You didn t mean goodbye, You meant, Please, don t let me go? I ve had people cancel sessions, or want more time between sessions, and if I start to take it as, Oh, I guess I m not that helpful to them, or, They don t like me so much, or, Okay, I guess I d better pull back also, I might miss the point. I might miss the point that they were needing space because they were scared, but actually there is another part of them that very much wanted to be in contact. There s others who are on the more maybe obviously attached side, who would perhaps get angry at me. I travel a lot, so I m intermittent sometimes in my presence and suddenly I find they re seeming annoyed with me. There, if I can help them to connect with the underlying hurt and can in some way genuinely apologize for it, it goes well or goes better. I might miss the point that they were needing space because they were scared, but actually there is another part of them that very much I m thinking of one guy in particular, a fellow I was working with around chronic pain issues, who was very disconnected from people wanted to be in contact. in his life. He feels like I actually care about him and understand him, and when he feels that, he starts canceling appointments, starts saying, Oh, this isn t really working. I need another way to work with my pain, and goes off in that direction. It s a very delicate balancing act for me because on the one hand, I want to give him his space; that s helpful if I just grab on, he s going to feel claustrophobic. But on the other hand, I really want to try to communicate that he doesn t have to be so afraid; that I will be there. I usually communicate that by giving him the space and saying, I m here whenever you want me, and perhaps checking in with him on other occasions. New Research on Yoga and PTSD Dr. Buczynski: Thank you. Thanks, Ron. Kelly, talk to us about other research that are related to these ideas. We talked a little bit about research with touch how about research with yoga and other things?

9 Next Level Practitioner - Abandonment Week 132, Day 5 - Critical Insights - Transcript - pg. 9 Dr. McGonigal: Yes. I wanted to give some context to a comment that Bessel had made about yoga for PTSD. I want to preface this by saying that longtime viewers might know that I ve taught yoga for two decades and I used to be the editor-in-chief of The International Journal of Yoga Therapy, which was the first scientific peerreviewed journal to look specifically at the therapeutic benefits of yoga. I m a big fan of yoga for physical and mental health conditions. But I wanted to add some caution to a comment that Bessel made about the current evidence for the benefits of yoga for PTSD, particularly in comparison to other treatments, such as medication. Yoga did indeed reduce symptoms of PTSD, compared to a seminar about health, but the conclusion is only a weak recommendation for yoga, as an adjunctive intervention for PTSD, can be made. I actually did my own literature review and found a very recently published review paper looking at all of the published studies on yoga for PTSD. I would say that I could only find one randomized control trial done by Bessel s group, and that particular study, which is published in the Journal of Alternative and Complementary Medicine, actually compared the benefits of yoga to a control group that was just a seminar in women s health. So it wasn t a comparison to medication for PTSD. They found that yoga did indeed reduce symptoms of PTSD, compared to a seminar about health. They did very nice long-term follow-up where if the participants continued to practice yoga, that continued practice was associated with continued reduction in symptoms. So it s a nice study but it s a single, small pilot study. Then the review paper (that I ll send to you so that people can see what s been done more broadly), this 2018 paper was only able to find seven randomized control trials, and they were mostly small, and often the control group was a waitlist control. No control groups that were specifically comparing it to standard medical and therapeutic treatment. Their summary was that meta-analysis revealed low-quality evidence for clinically relevant effects of yoga on PTSD symptoms compared to no treatment. Now, that was the best evidence low-quality evidence that s only compared to no treatment, not other known treatments; very low evidence for comparable effects of yoga and attention-control interventions so that s not even therapy; that s something like the health seminar. The conclusion is only a weak recommendation for yoga, as an adjunctive intervention for PTSD, can be made. More highquality research is needed to confirm or disconfirm these findings. When they say low-quality evidence they re not saying that yoga doesn t work; they re saying that when you look at the design of the studies, the confidence in This was published in BioMed Central Psychiatry; they often do these reviews to help physicians or clinicians make sense of the data. When they say low-quality evidence or very lowquality evidence, they re not saying that yoga doesn t work; what they re saying is that when you look at the design of the studies, the confidence in your conclusions that yoga works should be conservative and not making huge claims, because we just don t have the evidence yet. your conclusions that yoga works should be conservative. They re not reporting evidence that yoga doesn t work; there just is not high-quality evidence yet saying that it does work. I wanted to emphasize that because, first of all, clinicians who aren t reviewing the research

10 Next Level Practitioner - Abandonment Week 132, Day 5 - Critical Insights - Transcript - pg. 10 regularly might get an inflated sense of what we know. But also how important it is to understand what other people are familiar with so those who are looking at the research. If they re coming across articles like this, it s really helpful if those of us who are really enthusiastic, like I am, about yoga for mental health, to know what other people are looking at so that we don t come across as being zealots rather than someone who is simply interested in following the evidence, to help people heal. There s a lot of mixed or low evidence for things that are highly embraced Dr. Buczynski: Right. Dr. Siegel: Just to add one thing to that: I haven t seen a recent review, by the medical but my understanding in general has been that the efficacy of communities as well. medications for PTSD has been pretty weak over time. This is one of the reasons why the FDA fast-tracking studies using psychedelic drugs are looking promising in pilot studies, because traditional psychiatric medicines are really not very helpful for PTSD because they don t really work on psychological transformation. Dr. McGonigal: Yes, and actually it s not just what you might think of as either somatic or complementary. I mean, there s all sorts of language that physicians use to describe things like yoga. There s a lot of mixed or low evidence for things that are highly embraced by the medical communities as well. Dr. Buczynski: Exactly. Dr. McGonigal: It s more it s good to be conservative overall and not to make assumptions. Dr. Buczynski: Yes. That last point that you just made is really important: the tradition of yoga, or even all of mental health psychotherapy, isn t the only place that there s low evidence. There s a lot of things in the medical tradition that have fairly low evidence as well. Dr. McGonigal: Or that there s evidence that things are harmful, not helpful, and that s not being adapted in the clinical practice. Dr. Buczynski: Right. Yes. Dr. McGonigal: You see this happening all the time in our conversations as physicians, about things related to, say, cardiovascular disease. I just think it s great when any of us in any tradition or any field will try to follow the evidence rather than get ahead of or reject evidence when it comes in. Dr. Buczynski: The other thing I would say, Kelly, is especially that we need to be careful not to pronounce the evidence as more than it is. It doesn t mean that yoga doesn t work, and it doesn t mean that yoga wouldn t be helpful to your patient. It just means that you/we can t make a statement about the research showing something. There s a lot to be said for direct observation of what works when you re helping people. The research base is just one aspect of what can inform our work. Dr. McGonigal: Yes. We ve had this conversation, too: there s a lot to be said for direct observation of what works when you re helping people. The research base is just one aspect of what can inform our work. Dr. Buczynski: Yes. Right. Thanks. That s it for us for this week. We ll be back again next week to continue on with our question about Working with people who feel abandoned.

11 Next Level Practitioner - Abandonment Week 132, Day 5 - Critical Insights - Transcript - pg. 11 Right now, we d like to hear from you. What are your thoughts? What have you found that works and doesn t work? What are your reactions to things that we ve said? Please leave your comments below and do you touch your patients, for instance? We d like to hear about it, just amongst ourselves. This is a private Comment Board, so anything you want to say is fine; we just say please leave a comment below, and maybe take a moment to go up and read other people s comments, and even comment on their comments, and make the dialogue go further. We ll be back next week. Take good care, everyone. Bye-bye.