The Therapeutic Alliance and Psychoeducation
The first sessions of the treatment require special attention to the
therapeutic relationship. While Michael had been working with the SNT
therapist in supportive counseling, there was a shift in the emotional
and interpersonal dynamics in anticipation of embarking in a treatment
process that would focus on Michael’s trauma. He was uncomfortable about
the prospect of exploring rather than distancing from his feelings. All
aspects of the treatment increased Michael’s sense of vulnerability, and
in particular shame about his anger and social isolation. This initially
led to an exaggeration of Michael’s tendency to engage in a dismissive
and demeaning interpersonal style. For example, Michael’s therapist was
a lesbian and younger than him. Michael would sometimes chide the
therapist on her lack of lived experience regarding the AIDS epidemic,
what it meant to be a gay man during this time, and whether the
therapist could possibly be of any substantive help.
The therapist was sensitive to all of these issues. First, she quickly
highlighted that trauma impacts emotions and emotional well-being. The
problems that Michael experienced were common consequences of trauma
that many people experienced. A review of a worksheet listing the common
emotional consequences of trauma, which included anger, was affirming.
Michael’s shame and confusion about “Why am I this way?” was replaced
by a quiet reflection about the relationship between the loss of his
partner and friends, and the onset of his anger problems. While details
of this history would come later in the treatment, Michael noted that
the connection “felt true.” His feelings of shame began to be replaced
by curiosity and greater openness to exploring his history.
The therapist also expressed respect for Michael’s willingness to
explore painful experiences and feelings. Michael associated having
feelings with being feminine or weak. He took pride in his masculine
appearance and traditional masculine attitudes. It was one way he had
hidden his gay identity in his youth and had made him feel safe. The
therapist’s interest and steadfast connection to Michael as he initiated
his emotional exploration provided an antidote to the rising feelings of
shame Michael experienced at the beginning of the process. The therapist
would make comments such as “Thank you for sharing this with me.
Congratulations on these efforts. It takes strength to do this.” The
therapist provided an alternative perspective about the task in which
Michael was engaging: it was not shameful but rather courageous to
explore feelings.
The therapist did not combat Michael about his views on her competence
in the work. She acknowledged that the LGBTQ+ community was very diverse
and that there were substantial life experience differences between
them. However, she hoped to be helpful to him and that shared
experiences related to living as a member of a minority group as well as
her knowledge about ongoing concerns of the LGBTQ+ people would support
their work together. She also invited Michael to let her know when she
misunderstood him so she could correct her understanding.
Lastly, the therapist did not rush Michael into the world of feelings
but followed him as far as he was willing to go and respected his limits
in exploration. The first two sessions focus predominantly on increasing
awareness of emotions through attention to daily interactions and
resulting bodily sensations, cognitions and behaviors. In the early
phase of the treatment, every example Michael reported focused on anger.
The therapist suggested that the anger might be a protective shield
against the emergence of other, more threatening emotions. While Michael
agreed in theory, the practice of identifying and experiencing other
emotions was a slow process in which small steps were counted as
victories.