Developing an Emotional Sense of Direction: A Therapeutic Model for the Treatment of Emotional Abuse
By SaraKay Smullens, M.S.W., B.C.D.
Annals of the American Psychotherapy Association, Fall 2003, Vol.6.3.

Developing an Emotional Sense of Direction: A Therapeutic Model for the Treatment of Emotional Abuse

KEY WORDS: emotional abuse, group therapy, family life, education, therapeutic model, marriage and family therapy, five cycles

Abstract: This article describes a model for the treatment of emotional abuse to help clients heal from past relationships and avoid recidivism. It utilizes a process where clients work with a therapist, as well as with a group of other clients, to achieve an “emotional sense of direction” in love, friendship, and work. This model helps clients understand the five cycles of emotional abuse, and how the cycles have impacted them, using the concept of an “artist-guide” and an InnerSelf Dialogue technique. This model relies heavily on group psychotherapy, family life education, and the integration of individual, conjoint, and family therapy, as indicated. It is a model that works well with a broad spectrum of psychological frailties, including high functioning borderline personalities.

Introduction
I have devoted the last 20 years of my professional life to formulating a theoretical base that elucidates the intergenerational perpetuation of cycles of emotional abuse. The five cycles that I have codified (enmeshment, extreme overprotection, complete neglect, rage and rejection/abandonment) were first published in Annals in the fall of 2002.

Since that time I have been invited to many conferences, workshops, and study groups to present and discuss my findings. At these meetings, and in follow-up question and answer periods, I am reminded by colleagues how difficult it is for clients to see emotional abuse for what it is, primarily because the discovery usually involves parents or partners one feels dependent upon and loyalty toward, even though the loyalty may be ambivalent. Further, I am reminded that if a client is able to leave a threatening relationship, it is very difficult to avoid the selection of other diminishing relationships in the future. With this in mind I share the most effective treatment model I have found to treat emotional abuse and avoid recidivism.

Working with those who have endured repetitive cycles of emotional abuse during formative years taught me that clients reenact horrific patterns repetitively because those patterns are all they know and all they believe they deserve. But I have also learned that victims return again and again to ingrained replays of agony because they are trying desperately to fix something that feels broken in the deepest core of their selves. It feels natural to continue to return to the source of their torment and agony in order to finally “make it right.”

I see psychotherapy as an equal partnership between client and psychotherapist, one where the latter does all in his or her power to relieve the suffering that caused the client to seek help. My therapeutic goal is to provide a setting of trust and safety that will, as time passes, allow insight, hope, direction, and the opportunity to achieve autonomy—a quality of experience that provides an “emotional sense of direction” in love, friendship, and work in the world outside of the treatment room. I believe that even very complicated psychological concepts, if well understood by the psychotherapist, can be explained clearly and simply (as opposed to simplistically), and that such explanations do much to alleviate a client’s anxieties and increase motivation to change. I believe it is essential to help clients understand what has happened to them, why it happened, and to offer them concrete tools to encourage change.

My treatment model helps clients understand the five cycles of emotional abuse and how the cycles have impacted them. I use the concept of an “artist-guide” and an InnerSelf Dialogue technique that I developed as a vehicle for clients to leave past pain behind. As a result, clients from enmeshed or extremely overprotective families learn why they have been attracted to rejecting partners. Clients who had rejecting families see why overprotection can initially feel like love. Those who endured rage understand their attraction to continued rage and realize why rejection or neglect can initially feel like freedom, and they learn how to change the motivations that have caused them misery.

The following is my model according to my philosophy of practice and the methods of implementing hope and change that I developed through the years. It is one that relies heavily on group psychotherapy, which provides “a room of mirrors” as well as a “laboratory” where nonproductive patterns of behavior and attitude can be understood, worked through, and changed. My model also relies strongly on family life education, which provides a vehicle for teaching improved communication and intimacy skills, as well as didactic understanding of the cycles of emotional abuse that I have found alleviates the extreme anxiety that impedes intensive psychotherapy.

In addition, this model uses individual therapy (in the beginning of the treatment process, and as indicated), along with conjoint and marriage and family therapy as indicated. It can be used effectively by those in individual practices, in collaboration with colleagues in private practices, or in social service settings. It is a model that works well with a broad spectrum of psychological frailties, including high functioning borderline personalities. (One or two of the latter are regularly in each of the therapy groups in my practice.) It cannot be used to treat psychosis or (to protect confidentiality) pervasive character disorders.

Initial Contact With Client
When a client calls for individual, couple, or family therapy, I begin where he or she is. I try to meet the request of the initial contact person, realizing that if one wants to bring the entire family for a first session, there are reasons for that. For instance, in a recent family session, bringing all of the children was my client’s way of being able to tell me that the youngest child she and her husband had primary responsibility for—though he didn't spend all of his time with her family—was the child of her husband’s former lover.

I explain in the initial phone call that our first meeting is a two-way evaluation. I want to make sure that my therapeutic approach will be helpful in addressing the presenting problem. For instance, following an initial session, if I believe the client can best be helped by a pharmacological approach that may not involve me, I will make this suggestion and provide referrals. For other cases medication may be helpful in concert with our work. The other essential determining factor in a first interview is: will the client be comfortable with my approach. Our relationship must be a partnership. If this comfort and some resemblance of rapport or trust are not present, I provide a list of referrals I believe can be helpful.

Determination: Is Emotional Abuse a Factor in the Problem?
Serious communication, intimacy, and control problems in relationships addressed in therapy almost always emanate from one or a combination of perpetuating cycles of abuse. After clarifying the goals of our first evaluation session, I then move forward to fully discuss the presenting problem and take as complete a history as possible.

At the conclusion of the first session, the client/clients and I decide how to proceed: Individually? Conjointly? The entire family? A combination? Again, I am guided by clues from my client/clients.

Delineation of Contract Issues
My first introduction to the use of contracts in psychotherapy was in September of 1964, as a transfer student from the Catholic University School of Social Work to the University of Pennsylvania. At that time there was enormous rivalry, conflict, and even disdain between “diagnostic” schools like Catholic University, adherents of Sigmund Freud, and “functional” schools like Penn, which followed the teachings of Otto Rank. Rank was the only non-physician in Sigmund Freud’s 1906 select Viennese circle of followers, which also included William Stekel, Alfred Adler, Abraham Brill, Eugen Bleuler and Carl Jung, later joined by Sandor Ferenczi and Ernest Jones. But Freud and Rank had an ugly and traumatic break in their relationship. Rank believed that the separation process, not Oedipal rivalries and conflicts, was the primary obstacle to individualization and autonomy. He opposed unlimited therapy and introduced time-limited therapy, a period referred to by Penn professors as a “contract” between client and social worker.

In my own practice I have my clients put their contracts in writing. Prior to the beginning of the therapy groups, in individual sessions, each client delineates contract issues to concentrate on in the group. Such issues include: “Can I make my relationship with my parents, partner, son, daughter, in-law, employer, etc. more positive?” “I want to find out why extramarital affairs have been necessary.” “I have never been happy and want to understand why.” “I have repeated conflict with my boss and others in positions of authority.” Again, I begin where the client is. Contract issues may be as generalized or specific as the client needs them to be at the time. I tell clients that in time they will begin to understand how the cycles of abuse have led to their feelings of confusion expressed in their contracts. With insight they will see what cycles or combination of cycles have deterred their directions and opportunities for fulfillment in friendship, work, and love, and in this way begin the process of setting themselves free.

Introducing Time-Limited Group Psychotherapy
I have seen that the concept of “time limits”—this experience will end (as indeed, life itself will end)—propels clients to move forward. The emphasis is to find life and meaning in one’s precious days. No one knows which of these days will be our last.

As the client/clients and I proceed, I introduce the concept of time-limited group psychotherapy. This past year I had three such therapy groups in my practice. In each group all of the members had suffered a repetitive cycle (or combination of cycles) of emotional abuse. With each group I stress the essential importance of confidentiality. I place married couples in separate groups, and I give the couples the option to meet individually or conjointly with me. I tell my clients that if they or I feel it wise, occasional individual, marital, or family sessions can increase the effectiveness of our work together. In addition, some of the clients in the groups are in individual treatment with other therapists, and are referred to me for group therapy as an augmentation to individual work.

Putting the Group Together
Groups are comprised of six to eight members. Having a full history makes it possible for me to select a group experience for each member that will be as motivating and insightful as possible. For instance, in troubled marriages I try to select a group member who will help each client see when and how the cycle or cycles of abuse began (of course, this will take time) and how these cycles play themselves out in a marriage. I will place a client with a sibling problem, a parent problem, an authority problem, etc., with a group member who has characteristics of the person who is evoking the discomfort.

I stress the importance of confidentiality to all those entering groups. Groups meet for nine months—from late fall to mid-August. The meetings are two-hour sessions once each week. There is a winter break and an early summer break.

The Group Begins: Framing the Experience
1. General Expectations
I refer to group members as "colleagues," a metaphor to imply hard work, commitment to the group process, and trust. In the first session we discuss “rules” about attendance expectations. Clients are expected to attend all scheduled sessions. Planned absences are brought up in therapy. Most importantly I again stress the expectation of complete confidentiality, repeating what I tell my clients in individual sessions describing the group therapy experience. Nothing that happens in-group can be discussed outside of the group. This confidentiality applies not only to names (first and last) of all present, but also to matters discussed. There is no socializing before or after sessions so that important work done together will continue in an uninterrupted way from session to session.

2. “The Chosen Community”
It is no surprise to therapists that many clients never realize the option of distancing a relationship with an abusive parent or sibling. With this in mind I introduce the concept of a "chosen community.” We are all born into a family and community. With maturity and awareness we can decide who from this initial community (over which we have no choice) will join in our “chosen community” and the quality of trust and involvement we are wise to invest in each original member. We also decide who will be added to our chosen community and whom it may be necessary to exclude.

3. Life As Art
I have long believed that art and literature provide moving and effective ways to help clients learn about themselves and the universal challenges of all humankind. With this in mind I share selected passages from history and literature that demonstrate:

• The importance of facing reality.
• The importance of taking accountability of one’s life.
• The importance of recognizing one’s pain so that it cannot continue to cause emotional blindness.
• The importance of self respect and mutual respect in personal and professional settings.
• The importance of trusting communication in all settings.
• Such passages include:
• Plato: “The life unexamined is not worth living.”
• George Santayana: “Those who cannot remember the past are condemned to repeat it.”
• Tennessee Williams: “When something is festering in your memory…laws of silence don’t work….Silence about a thing just magnifies it. It grows and festers in silence, becomes malignant….”(from “Cat on a Hot Tin Roof”).
• Arthur Miller: “And I bent to its broken face, and it was horrible…but I kissed it. I think one must finally take one’s life in one’s arms”(from “After the Fall”).

4. The Artist-Guide Within
Otto Rank also introduced the concept of an “artist” in every human being. He believed that successful psychological therapy involved freeing the artist. In my work I refer to this vision and potential in each of us as our “inner-artist-guide,” our individual inner voice that, freed from pain, allows us to understand cycles of abuse that have eroded hope and direction and propels us to move forward, free from their perpetuating destruction.

I do whatever I can, within the realm of professionalism, to ease the pain of the clients I am privileged to work with in order that the process of insight, awareness, and healing can begin. This beginning leads to the ability to put learning and experience together in order to be able to trust feelings and develop common sense. This combination is the artist’s voice, a guide for the slippery slopes of life—present and future.

If this process of freeing the artist within can begin, it will continue to grow. With every two steps forward, there is the inevitable one step backward. But the step that remains is ever a building block for the future.

5. Contracts as Focus
Naturally, in the first group introductions are made. After two weeks together group members are usually ready to share contracts with each other. After they share contracts, members each comment on what is touched in them about their own lives and offer to help colleagues stay focused on addressing their expressed problems. During these introductions, I encourage clients to face each other and make eye contact. Often this exercise encourages clients to make further additions and refinements to their contracts. After the group member sharing, the client and I each sign the contract, and I also promise and firmly commit to be as helpful as possible in efforts to address his or her delineated goals. With each offer of support, including mine, the client is encouraged to say how he or she feels and has the choice of accepting or rejecting each specific offer. Clients face each other during this experience, and I encourage them to make eye contact. Thus begins a process of shared intimacy and honest communication that often is a client's first experience in this quality of trusted environment.

In the mid-point of group, clients again share their contracts, and the experience in feedback is repeated. But this time, each colleague can offer an evaluation of how his or her colleagues are progressing. Once again they offer their help in pointing out to their colleagues if they are or are not working together to attain contract goals.

Obviously, this quality of authentic communication in an arena of trust and confidentiality is a metaphor for what clients become motivated to find in the world outside of the treatment room. Again in these sharing experiences, facing each other and maintaining eye contact is stressed, as is a quality of communication that is honest but also respectfully expressed if one is frustrated by another’s behavior. This "authentic communication" is often in itself the biggest revelation of group members who, never trusting themselves, had not learned to trust appropriate friends, co-workers, employers, lovers, and partners.

Use of “The Chisel:” Tempered by Trust, Kindness, and Humor
As we move from the mid-process sharing contracts, clients are more able to understand how difficult and complicated change is and how they can help each other endure the time-tested reality that the cure is often worse than the disease. They also help each other see, by viewing glimpses of the light at the end of the tunnel, that the pain they will face is, and will continue to be, worth it. Again and again, they encourage each other to face the impact of the five cycles of abuse on their personal lives, their professional lives, and the communities they live in. There are also times when we discuss the disastrous societal ramifications of the cycles and the personal/professional/political continuum of emotional abuse – i.e., the Emperor’s New Clothes Syndrome: emotional abuse is so prevalent in our society that when a community leader or elected official is abusive to citizens it may not be seen or experienced as abuse.

My clients also learn that in-depth therapy, which will lead to change, involves “psychological surgery,” and that such surgery can only be performed in an arena of trust. When defensiveness is at its highest and acting out is at its peak, what we call “the chisel” can be used only if it is cushioned by careful thought, knowledge, awareness, and kindness. In this intervention we often engage the use of humor.

My grateful thanks to Albert Ellis, who showed me how effective the marriage of humor, song, and insight can be, and how a little bit of laughter does indeed help the medicine go down. Sometimes clients and I sing the following to the tune of “I Had A Little Chickie.” (And believe me, my inability to come anywhere close to carrying a tune usually makes even the most resistant, angry, and terrified client laugh, or at least smile.) Clients then use the song (and the associated smiles) as they use the InnerSelf Dialogue for themselves:

The Chisel Song
Ohhh, I have a little chisel and it must be used to see
How my contract issues can work for me.
If I will not see I’ll continue to fall
And I’ll never find life’s joys
In spite of it all!

InnerSelf Dialogue
As we move forward in our work with new intimacy and awareness, as well as levity to cushion the pain that we must face and work through, an InnerSelf Dialogue process has been slowly crystallizing in each client. It is integrated with the Artist-Guide within described earlier. At this point, most clients are well along in their identification of attitudes and patterns of behavior that result from a cycle of emotional abuse. They are ready to begin to integrate a Five Step InnerSelf Dialogue Process that has been discussed, but is now emphasized far more, to help them continue to clarify, focus, and will themselves to change.

Step 1. Spotlight: I see, can, must, and will!
Clients have learned to identify nonproductive attitudes and behaviors (i.e., “Why try?" "I’m worthless." "I’ll just pick fights or let others pick fights with me,” etc.) They have an understanding of why these attitudes and behaviors have developed. They have worked through at least some of the pain that has kept self-destructive patterns embedded. Clients urge and encourage each other to use their “inner-artist-guide,” their own inner voice freed from pain, to help them adopt an “I see, can, must, and will” attitude to formulate new attitudes and behaviors ("Of course I can try. I'm a valuable human being, deserving of respect and fulfillment." "I will communicate my feelings, needs, and desires maturely." “I will work to develop an emotional sense of direction.”)

Step 2: Orange Light: Danger Ahead!
Clients urge and encourage each other to see the dangers they have created, and learn to practice necessary changes in their everyday lives. They help each other fully understand and appreciate how important these new adaptations are and the differences they make.

Step 3. Red Light: Enough is Enough!
With self-awareness, insight, and support, clients see themselves more and more clearly and help each other stop ingrained nonproductive attitudes and behaviors resulting from cycles of emotional abuse.

Step 4: Green Light: Just Say Yes!
Clients will themselves to change and support each other as they continue to integrate positive approaches and reactions into their lives. They practice their new approaches to love, friendship, work, and all involvements important to them. Together they review upcoming events and plan for positive, life-affirming attitudes. They remind each other with conviction that practice is essential and that it is fine “to fake it ‘til you feel it.”

Step 5: Limelight: The Artist-Guide Remains Free!
Clients practice at home, preparing for a time when group will end and they will continue their “InnerSelf Dialogue” independently in their lives until it becomes second nature. They see that having worked through the pain of emotional abuse and understanding its origin frees their “inner-Artist-Guide,” their own inner voice, to help them put their knowledge, life experience, and feelings together to know what choices are best for them.

Group Ending
What has been shared by victims of emotional abuse is often the first experience of self-respect and mutual respect that they have known. A two to three week “Ending Process,” involving a final sharing of contracts (often modified by clients from the original contracts as work progresses) and thorough good-byes, is essential. As colleagues say goodbye to each other, their changes are beautiful to behold.

Individual Assessment
In the last 15 minutes of the final group session, I schedule an individual appointment with each client. Approximately two weeks after the group concludes, I meet individually with members to assess progress. Roughly half of the members of each group feel their work is concluded. The other half believe they have realized new work to concentrate on and wish to begin a new group the following fall.

Conclusion
By the conclusion of an intensive group experience, clients have seen and felt that the pain of emotional abuse that brought them to therapy can propel them toward growth and change. They have experienced the difference between life’s unavoidable pain (the pain of growth and loss) and the pain in life that can be avoided. They have learned to identify the source of their individual pain and to understand its repetitive, malignant, intergenerational cycles. They have seen through experience that emotional abuse is found in all socioeconomic backgrounds and professions, and that the deterioration of confidence and self-esteem that brought them to treatment—and the resulting muddle and confusion—is its inevitable outcome.

During group therapy, clients have developed a strong understanding of how one cycle or a combination of cycles of emotional abuse have undermined their lives and choices—and what they can continue to do to determine change. With this insight, they have achieved an awareness of new options, hope, and healing. The authentic, quality sharing they experienced helped them identify those in the world outside the treatment room who also know its importance and want to work toward its incorporation into their lives.

Reflections such as, “My life makes so much more sense now;” “Between my Artist-Guide and my InnerSelf Dialogue I feel able to handle what comes my way;” “I see directions I never saw before;” “I feel better because I understand what went wrong;” “I can finally let go and stop trying to control everyone and everything around me;” “Things aren’t perfect, but they are more hopeful;” "This has been my first experience in kind, trusting, and honest relationships;” “I finally know the difference between expressing differences of opinion and depleting, pathologic arguments;” “I finally know how to avoid the pain in life that is avoidable, where I have gone wrong in love, friendship, and work, and how to make it right;” “I have felt it, so I will find it. I finally have an emotional sense of direction,” and “I will miss you all very much, but I will keep what we have learned together with me forever” are shared with new insight, strength, maturity, and optimism.

About the Author
SaraKay Smullens, M.S.W., B.C.D., is a Diplomate of the American Psychotherapy Association and has been a member since 1998. A marriage and family therapist in private practice for over twenty years, she received her master’s degree from the University of Pennsylvania. The best-selling author of Whoever Said Life Is Fair? and Setting Yourself Free: Breaking the Cycle of Emotional Abuse in Family, Friendships, Work and Love, Smullens is is known nationwide for her work in healing emotional abuse. Considered an activist in the prevention of emotional and domestic abuse, SaraKay has dedicated her life to helping people develop the attitudes and skills they need to recognize abuse and eradicate it. She is a frequent guest columnist for Philadelphia area newspapers and has appeared on Oprah, as well as numerous radio and television interview programs. To read more about her visit www.sarakaysmullens.com.