"I can tell that you really listen to me. I can see in your eyes that you listen from the heart."
- Comment of a 28 year old woman in remission from cancer
For the past 10 years I have worked as an oncology social worker with Cancer Care, Inc., a non-profit social service agency, based in the New York, New Jersey and Connecticut area, providing practical assistance and free individual and group counseling to people with cancer, their families, and the bereaved. Cancer Care social workers provide counseling in our offices, in patients' homes and hospital rooms in our geographic area, over the telephone nationwide through our toll-free counseling line,1-800-813-HOPE, and through the Internet. For about 3 years now focusing has been an invaluable tool for my own growth, generating frequent insights and change. Two years ago I began to participate in a Focusing Institute Training Program for Psychotherapists led by Dr. Mary Hendricks, and I have increasingly integrated focusing and focusing-oriented interventions into my work at Cancer Care. Using focusing, many of my clients have made more rapid progress adjusting to life changes and resolving problems. Focusing has also given my clients and me the skills to work more effectively with the very powerful emotions evoked in both of us by the experience of serious illness, dying and death. As was expressed by one woman, whose reaction to her cancer diagnosis was complicated by a long history of unresolved losses, "This is different from anything I've ever experienced; I feel like I'm finally getting somewhere." I would like to describe the changes in my practice in two areas: changes in basic therapeutic attitudes and assumptions; and commonly used, focusing-oriented interventions.
Changes in Basic Attitudes and Symptoms
More important than offering new interventive techniques and skills, focusing has helped me to recover and deepen my commitment to certain attitudes and values that promote emotional health and coping. I'd like to discuss some of the most important ones.
Focusing encourages us to view the client as an autonomous, creative individual whose core self is seeking to cope and to grow. My task as a therapist is to observe, identify, support and perhaps facilitate the process of this autonomous growth. I must listen to the "voice" of the client, to every time that she or he uses the word "I," and join and support that "I" as it strives. I recall one patient who came to see me as she prepared to undergo high dose chemotherapy and stem cell transplantation, a difficult procedure used in women with a higher risk of recurrence. I felt frustrated during our first two sessions that she spoke little of her cancer and instead complained about her intimate relationship. I became exasperated with her sense of helplessness and her resistance to seeing her own responsibility until I was able to join her empathically and listen for the honest effort she was making to understand and to act in her life. When I joined her in this way, she felt heard. I was no longer critical and frustrated, and I was able to support and help her to notice her positive efforts and the patterns that were blocking her. From this point on our work shifted, and this became one of my most rewarding therapeutic experiences.
This commitment to the client as the director of his/her own process is extremely important, especially in an area of practice such as psychosocial oncology. When professionals work with clients who are experiencing intense feelings of sadness, fear and anger as they face serious illness and perhaps death, we are often tempted to assume too much responsibility and may attempt to "rescue" clients from distress. This can actually disempower the client and lead to professional burnout. Instead, focusing helps us to trust that there are ways that the client can be with his/her own experience, even in the midst of the dying process, that can contribute to psychospiritual growth.
In our professional training as social workers, we are encouraged to give as much time to assessing our clients' strengths and resources as we devote to identifying their pathology, but I know that my work was still skewed toward attending to deficits. (Perhaps we do this because we are more interested in what we can do to help rather than in what the client can do for her or himself.) Focusing taught me to look for, and be excited by, the healthy, growing edge in my clients and to help them to notice and to be enthusiastic about their strengths. I remember working with a 45 year old, single, unemployed, chronically depressed daughter of a manic-depressive, character-disordered, cancer patient. My client found it enormously draining to care for her sick mother because her mother continued a life-long pattern of emotional abuse. It was a fairly dismal relationship and situation. But focusing helped me to notice the life and energy that came into my client's face and voice when she mentioned her cat. This was the first sign of hope in our sessions and, rather than redirecting my client's attention back to the identified problem, I invited her to tell me more about her relationship with and care for her cat . My client then said the first self-affirming thing I had ever heard from her: "I just know that I could write a really interesting children's story about that cat." Her love for her cat and her creative, playful impulse were the first "green shoots" of the growth of her authentic self that we would protect and nurture together.
Focusing also helped me to look for the adaptive, healthy impulse behind defensive behavior. I had learned to "respect defenses" before, but focusing helped me to be more appreciative and supportive, and gave me language with which to express this and work forward. For example, a client who has dealt with several recurrences over the past few years told me recently that she was experiencing shortness of breath. She mentioned worrying about being anemic or having emphysema, but made no mention of worry about cancer. When I asked her to notice how she was feeling inside her body, she said she felt detached. I reflected this back and she said that she felt like maybe she was hiding. I acknowledged that there is a "hiding" place inside and then I suggested that she check inside whether this place wanted to stay hidden for awhile or was hoping to be found. She said she wasn't sure. I suggested that she might tell the place that it could stay hidden if it needed to. She was quiet for awhile but then said that she was afraid that she might be having another recurrence, and we were then able to work with this. This gentle, supportive approach toward defenses and resistance helps clients to feel safe, and to keep themselves safe, until they have the resources to deal with what they're repressing. Focusing has helped me to really know that sadness, tears, fear and anger are valuable and authentic, that both the client and I can tolerate and "sit with" them, and that the client can grow forward through them. I have come to understand that these emotions are better understood as parts of the self which can be related to, recovered and integrated rather than excised. For example, when the client I just mentioned told me about her shortness of breath, my first panicky thought about this woman I've come to care about deeply was, "Oh, no. It's spread to her lungs." Focusing enabled me to be compassionately aware of my own feelings of fear and to give them a place inside, acknowledging, "Of course, there's a part of me that's panicky and afraid. That's there." I was then able to work more calmly with my client's experience, helping her to gradually come to awareness of her feelings. My calmness and awareness of my own fear helped her to be somewhat centered as she faced her own.
Finally, focusing has helped me to understand that change happens in the present. Often a client will come into my office and report on all the traumatic events since we last met: "The nurse said this. . . .the chemo caused that." Instead of getting trapped in reporting or working on the wrong issue, I help clients to look for what's there right now that needs attention. One of my clients, a retired social worker, would often talk nonstop about every thought and experience. One day she was filling me in on her entire conversation with her doctor, how much she appreciated talking with him, how well he treated her, how she was educating him about the emotional needs of patients, etc. I asked her, "So, tell me how you are right now inside." She paused, checked, and then said, "Angry." It seemed that she was using all her words to try to protect herself from or change her true feelings. We were then able to work on the real issues needing attention.
Common Focusing-Oriented Interventions
In my early months of trying to integrate focusing into my work, I often tried to teach people to focus formally. I had begun to lose faith in traditional methods of talk therapy, and I felt that only the depth work permitted by focusing was of much benefit. With those who were already attuned to their own inner experience this was beneficial, but with others it became an intrusion. As I have become more experienced as a focuser myself, I have been able to more gently and naturally integrate focusing-oriented interventions and process suggestions as Dr. Gendlin describes in his new text. Over the weeks I explain a bit more about what I mean and, as clients begin to experience some of the benefits, they ask how they can learn more about focusing. Then I can offer reading, training or referral to training workshops. In this section I want to describe some of the most common interventions I use that help to deepen my work.
Of course, the foundation of all the work is empathic relating to the client. I heard Gene Gendlin say in a lecture once, "If in doubt, reflect back." So, reflective listening is key. But I learned from Drs. Janet Klein and Mary McGuire that, for reflective listening to be effective, I must drop my awareness into my own body and listen from my felt sense and not from my rational intellect only. This is what enables me to "be with" the client, for her or him to feel companioned, and for my responses to feel genuine and not stiff.
I also regularly direct my clients to notice the bodily felt sense of a problem. I often will drop or close my own eyes and gesture toward my throat, chest and belly to model looking inward, and ask them if they notice anything in their body about that issue or problem. It's usually good to do this at first about some issue or emotion that I can see is having a strong impact. When I ask them to describe what they feel, I have found it helpful to suggest, "Describe what that feels like in your body so I might be able to imagine what it would feel like in mine." This often brings more detailed description of the felt sense itself rather than an emotion word or thought. As they get more experienced with working with the felt sense, I try to keep directing them to check back with it throughout the session.
It's also essential to teach and to model a focusing attitude or an accepting, compassionate attitude toward all the feeling states and thoughts that come, and this can be introduced from the very beginning of counseling. I also try to help clients to identify the critic and begin to notice how much they are relating to themselves from that place. I try to help my clients to take a focusing attitude even toward the critic, and to look for the positive impulse even there. I might say, "Okay, there it is, right there. You made a decision about what treatment felt best to you. And you felt more at ease in your body. And then that voice started up saying very negative things like, ‘But you're probably taking the easy route. You never make the best decision.' That's the critic part. And we want to understand better why that comes in there. But it's not a reliable voice for your decision."
It has been invaluable for me to identify feeling states that clients mention as "parts" of the self or "places" rather than the whole self, and to help them to create and experience some distance or differentiation between the self and their feelings. I have been amazed at how effective this is even with very intense emotions of fear, anger and sadness related to dying and death. For example:
Cl: I just woke up with this feeling. A lump right down there. And it feels kind of cold and hollow.
Th: (Reflected back.) Can you find a word that describes that cold, hollow lump?
Cl: . . . Terrified.
Th: There's a part of you that's terrified. It's not all of you but there's a part of you that's terrified. . . .Can we be with that part, next to it, maybe just sitting with it as a friend. . . .And maybe we could ask right into that place, ‘What's so terrified? What's that about?' And we could just wait awhile and listen."
Cl: . . . I'm terrified of going back on chemo.
Th: Oh, there's a place inside you that's terrified of going back on chemo. Can we just make some space for that?. . . .Can we be with it?. . . .And be a little bit curious about what's so terrifying?
Cl: . . . Oh. . . .it's about the loneliness of it.
Th: Oh! The loneliness of it. Ah. There's a part of you that feels a lot of loneliness when you're on chemo.
Cl: Yes, everyone at home has to go to work or school and I just have to stay home. And I don't even feel well enough to sit at the dinner table and talk. The smells make me feel awful. There are just so many books you can read. It just gets so lonely it feels unbearable.
This was a wonderful example of how focusing helps client and therapist to tolerate an extreme emotion like terror and also leads to somewhat surprising and new insights when we really ask the felt sense place. I would not have guessed that this was what was frightening my client.
Besides the questions that help a client to explore the meanings implicit in their felt sense of a problem or situation, it's also important that we try to help them to move forward. So, I ask questions like, "What does that need?" "What would help that place to feel a bit better?" or "What small step forward would help?" The following excerpt came from a session with a woman who was told that her cancer is in remission.
Cl: I don't know how to do this, to live in the face of this uncertainty.
Th: You don't know how yet. . . .What does it feel like inside your body?
Cl: Like a frightened little girl is inside me who wants to trust, but she's very tentative.
Th: (Reflected back.) And what does that little girl need that would help?
Cl: Someone to hold her hand.
Th: (Reflected back.) Can we imagine holding her hand and keeping her company?
Cl: Yes. . . .I think so. . . .That feels better.
Focusing has tremendously deepened my work with cancer patients, their families and the bereaved. It offers a theoretical orientation that is humanistic, growth-oriented and empowering. And focusing-oriented skills and techniques enable clinicians and clients to be aware of their own experience, to tolerate potent feelings and to work toward resolution and development. I find that I am more able than ever to work with intense reactions, to follow patients who are in physical and emotional pain, and to do sensitive counseling sessions, even over the telephone for clients across the country who have no access to face-to-face counseling. I am convinced that focusing has much to offer the field of psychosocial oncology and the millions of patients and families dealing with all life-threatening illnesses.