Windhorse Treatment: Group Dynamics Within Therapeutic Environments
Authors
Jack Gipple, Senior Clinician, Windhorse Community Services
Chuck Knapp, Co-Director and Senior Clinician, Windhorse Community Services. Correspondence should be addressed to chuck.knapp@me.com.
Previously published as: “Windhorse Treatment: Group Dynamics Within Therapeutic Environments.” Group: The Journal of the Eastern Group Psychotherapy Society 39, no. 3 (Fall 2015): 199–239.
This description of the Windhorse team style of treatment for people with extreme states of mind may not initially be recognizable to group psychotherapists as group psychotherapy, but look closer. A Windhorse team is full of very subtle and complex overlapping group processes that any group leader would recognize, just organized in a different manner. A Windhorse team is an intentional group comprised of a client, the client’s family, and various clinicians, including psychotherapists, and psychiatrists, all done with the intention of being for the benefit of all. Group phenomena are in play in the dynamics among all the members of the team: clients, family, and clinicians. As will be shown, the phenomena of groups are in play regardless of who is designated the client and who the clinician. Windhorse-style teams give a great deal of attention to the interactions between staff members and skillfully make use of the induced feelings from the clients and their family systems to the team process. Understanding the group dynamic within this treatment model is relevant to more than just practitioners of the Windhorse model; it is also highly relevant to the work happening at any psychotherapeutic treatment facility. This paper is focused on describing these subtle group processes at work in a Windhorse team.
It should be noted that this paper is adapted from presentations given by Chuck Knapp and Jack Gipple at the 2013 and 2014 American Group Psychotherapy Association conferences. As such, the structure represents two different presenter’s perspectives, discussing Windhorse treatment and group processes through contrasting and complementary descriptive lenses. The following is a summary of each section.
Section I: Jack will describe the key therapeutic and structural elements of the Windhorse model.
Section II: Chuck will introduce the interpersonal interactions, exchange, and split transferences, that principally drive group dynamics within the therapeutic environment.
Section III: Jack will introduce a meta-view of the therapeutic dynamic between the client, family, and clinicians, over the life of a Windhorse team.
Section IV: Chuck will describe group dynamics within supervision and family work.
Section I—Introduction to the Windhorse Approach
When Chuck Knapp and I (Jack Gipple) use the term windhorse, we are sometimes referring to the name of the organization, sometimes to the treatment modality, and sometimes to the principal of wakeful uplifted healing energy. “Windhorse” is a direct translation of the Tibetan term lungta, which means “uplifted or healing energy.” As an activity, windhorse is the practice of cultivating a strong connection to “unconditional confidence” and to rousing an innate energy in order to overcome obstacles. Windhorse therefore also means the vitality and healing energy of a wakeful present mind (Kneen, 2002). This is a frequent state of mind when people are living and relating to each other in a healthy way. Our goal in Windhorse-style treatment is to create a social grouping around a client that is imbued with possibilities for a wakeful positive environment filled with vital healing energy that benefits all members of the team.
We often refer to a Windhorse team as a healing mandala (a Sanskrit term for a system of relationships). To see something as a mandala is to recognize the interrelations within the system where change within any element of the system affects all elements of the system. Mandalas are systems, societies, or organized webs of relationships. Mandalas are individual systems, family systems, organizations, even states and nations. Groups are also mandalas. A Windhorse team is an intentional healing mandala, a group formed for the mutual healing and benefit of everyone on the team.
The work we do is part of a larger Windhorse Project that has been going on since the 1980s. Currently there are about eighty treatment teams and seventy employees operating in the Boulder, Colorado, area through Windhorse Community Services. There are other established Windhorse projects operating in Northampton, Massachusetts; Vienna, Austria; Turin, Italy; San Luis Obispo, California; and Austin, Texas. There are also numerous smaller individual teams in other locations that are supported by our service in Boulder, Colorado, or by one of the other established Windhorse Projects.
◈ Windhorse History and Roots
Windhorse, the treatment modality, came from a collaboration between Ed Podvoll (1936–2003) and Chogyam Trungpa (1939–1987). Chogyam Trungpa was a Tibetan Buddhist teacher, master of many Buddhist practices, deeply steeped in view and practice of Buddhist psychology, and founder of the Naropa Institute in Boulder, Colorado. Ed Podvoll was a trained Freudian psychoanalyst and psychiatric director of Chestnut Lodge in the 1970s, and later at Austin Riggs. Some of Ed Podvoll's early trainers, supervisors, and influences were Harold Searles, Otto Wills, and Frieda Fromm-Reichmann. While at Austin Riggs, Ed Podvoll became interested in Buddhist psychology and mindfulness practice. After meeting Chogyam Trungpa, he left Austin Riggs to help establish the Contemplative Psychology department at the Naropa Institute, now the Naropa University, in Boulder, Colorado (Knapp, 2008, 276).
In the 1980s, Ed and a group of his students formed a supervision group in which the groundwork for Windhorse-style work was laid. This group of people formed the first basic ideas and practices of a Windhorse team and identified the original elements of the model. Besides being clinically supervised by Ed Podvoll, the group continued to be inspired by Chogyam Trungpa. Although the Windhorse model has continued to evolve, the core concepts of a Windhorse team were established in this time period.
In 1990, Ed Podvoll published a seminal book on the Windhorse model, originally titled The Seduction of Madness, and later republished under the title Recovering Sanity (Podvoll, 2003). A key concept underlying the Windhorse model is a confidence in the fundamental sanity or basic goodness of everyone. The importance of a belief in basic sanity is a confidence that, in a healthy and sane physical and relational environment, people have the innate ability to recover. This paper describes the Windhorse model as it is currently practiced and discusses the intricate overlapping group phenomena that are at work in the healing environment of a Windhorse team.
◈ A Windhorse Team
A typical Windhorse team is built around an individual who is experiencing extreme states of mind: psychosis, depression, bi-polar disorder, substance and behavioral addictions, OCD, or PTSD. Commonly, a Windhorse client is suffering from more than one condition, and often from a complex set of overlapping conditions that have been unsuccessfully treated by more conventional means. Team staffing is individually tailored to the needs and budget of the client. In this paper we describe a large team in order to illustrate the many layers of group phenomena at work in a Windhorse-style treatment team.
◈ The Household
The client and the client’s family rent a house or apartment to serve as the treatment household. In the Windhorse model, the treatment household belongs to the entire team even though it is the primary residence of only the client and the therapeutic housemate. Into this treatment container we bring the team members and groups. Many of the team dynamics happen within the treatment household.
Chart of Team Roles and Elements of Each Role
◈ Basic Attendance
The primary therapeutic practice of a Windhorse team is called basic attendance (Podvoll, 2003; Knapp, 2008, 281). Basic attendance is an awareness practice that spans the attentional quality of a psychodynamic clinician and a meditation practitioner. Both of these traditions are based on paying attention to the present moment and to the subtle, constant interplay between people in a shared physical environment. Basic attendance is the awareness practice of all Windhorse clinicians. The individual trained in basic attendance is aware of his or her own thoughts and feelings and is simultaneously aware of the client’s interactions with the environment, team communications, and apparent states of mind in other team members. Each of these elements has a history to it and the basic attender naturally includes his/her memories of what has happened regarding, for example, what has happened in the team household. The present moment awareness always has a dimension of subjective past, present, and imagined futures to it. All of these elements of the basic attender’s awareness are moving against a canvas of spacious neutral awareness, a quality of mind that is developed in both contemplative practice and psychotherapy practice. In psychotherapy practice it is sometimes called the observing ego.
The practice of basic attendance is generally taught as a one-to-one dyadic practice, the clinician basic attending to the client. In a Windhorse team, one of the team roles is called a basic attender. The individuals in this role are referred to as doing basic attendance, but it is important to keep in mind that all clinical members of the team, including the therapeutic housemate, are practicing basic attendance while they perform their role on the team. All Windhorse clinicians are also asked to maintain some form of contemplative practice, such as sitting meditation or yoga, since this is essential in the skill of basic attendance and requires practice and familiarity to develop.
Basic attendance is not a therapy session. It is time the client and clinician spend together in relationship. Basic attendance can include activities like hiking, attending classes, or doing common household chores, like grocery shopping or cleaning. Generally, the everyday activities that are favored are those that synchronize body and mind and that integrate mindfulness practice in action, rather than activities that disassociate people from their environment and from each other. Whatever the activity, the most basic starting point of the basic attendance shift is to show up and be present, and to be aware of one’s own thoughts and feelings arising moment by moment while with the client.
◈ Mutual Recovery
Another primary practice of clinicians in the Windhorse model is mutual recovery, the recognition that, while a team is set up for an individual client, it is for the benefit of the team members and the client’s family as well as the identified client. We are human beings long before we are clients and clinicians, and as such we are all deserving of self-forgiveness and compassion. A natural outcome of this is recognizing that the healthy team will at times focus on the recovery process of the clinicians.
The practice of mutual recovery is characterized by a deepening sense of maitri—a Sanskrit term for healthy self-love and acceptance. Like the wakeful healing energy of windhorse, maitri is both a treatment practice and a treatment goal. It underlies all team treatment goals and the development of all clinical skills. Maitri is contagious—it is easiest to develop maitri for oneself in an environment of people who already embody this quality of mind (DiGiacamo & Herrick, 2007).
◈ Team Structure and Schedule
One last element of a Windhorse team is the diverse structure of treatment groups within a Windhorse team. The team is held together in a structure of individual sessions, team groups, and family groups. The team has a weekly schedule with a specific number of basic attendance meetings as the backbone of the team structure. Typically a client coming out of a hospital situation will have two, or even three, three-hour meetings with a basic attender each day. In addition there is one house meeting per week, during which the team leader facilitates a meeting discussing the issues coming up within the household involving the client and the housemate—not only difficulties, but also planning meals, organizing the house, and establishing new protocols for keeping the household running smoothly for everyone’s benefit (Fortuna, 1994).
Meeting Structure and Attendees
There is also a weekly team meeting that includes the client, the basic attenders, the team leader, the therapeutic housemate, the psychotherapist, and the team supervisor (periodically the psychiatrist is also present). The client generally does not attend all of these team meetings so as to leave time for group supervision. Supervision within a Windhorse team is done in the spirit of mutual recovery. At any time supervision is for the benefit of any member of the team, since each member has a unique location within the team mandala and is working with different emotional dynamics. Often this kind of group supervision is as simple and complex as consciously exploring the feeling and thoughts each clinician is having at the time of the meeting. From this, each member is able to see their position in the team mandala. This kind of mutual supervision can happen with the client present or not. Chuck will discuss supervision and the phenomenon of exchange at more length in the next section.
Sometimes a team meeting this large is overwhelming for clients, especially at the beginning of treatment, and they may opt out of the team meeting entirely. It then becomes a matter of timing and a goal for the team to help the client tolerate joining the larger meeting. This may take a few weeks, a few months, or longer before the client is able to tolerate meeting with the entire team. This is often a powerful integrative experience for a client to join in a group process involving all of the members of his or her team. There are also team planning meetings, psychotherapy meetings, psychiatric meetings, and family meetings.
Section II—Exchange, Split Transferences, and Group Dynamics
With the overview of the Windhorse therapeutic process providing a general understanding, we will now dive into a discussion of some of the group dynamics within a team. In order to do that, we first need to understand one of the key drivers of these dynamics: exchange.
In the early 1980s, within the practice and literature of contemplative psychotherapy, we began recognizing experiences in the presence of our clients that weren’t adequately explained by the concept of countertransference. While countertransference points to the experiences and responses that a therapist might have when working with a client, some of which may interfere and some of which may create a helpful basis for the relationship, we were identifying a non-conceptual level of experience that was more primitive relative to psychology, underneath it, and earthy. This experience appeared to be a by-product of meditation practice in general, and one in particular, tonglen (Chodron, 1997) that involves the intention to exchange oneself for other. This discipline of exchange cultivates an attitude and action of actually taking on and accepting another person’s pain and states of mind. It is recognized that meditation practices utilize the naturally occurring workings of the mind and body in order to create awareness. As such, the practice of exchanging oneself for other works with the “continuous rhythm of movement: an ebb and flow of mind and thoughts and emotions, naturally, though unconsciously, occurring between us almost all the time, and probably since infancy” (Podvoll, 2003, 339).
The field of brain research has come to better understand the brain/body physiology that occurs when people have such immediate and direct experience of one another, consciously and unconsciously. Goleman states, “The circuits for emotional empathy begin to operate in early infancy, giving a primal taste of resonance between ourselves and someone else. In the brain’s development, we are wired to feel another’s joy or pain before we can think about it. The mirror neuron system, a part of the wiring for this resonance (but by no means the only wiring), kicks in as early as six months” (Goleman, 2013, 103). Siegel has created a view and clinical practice around “resonance,” as a state which may include the experience of “feeling others’ feelings.” Within a state of resonance and as a function of the “neurobiology of we,” subcortical shifts can be measured, such as changes in our heart rate, breathing, intestinal functions, endocrine system, muscle tension, facial expressions, and voice. He goes further to describe how we can cultivate not just awareness of this particular sensitivity of one’s body and mind, but how to invite resonance as a broad-spectrum form of awareness of self and other (Siegel, 2010).
Within the Windhorse approach, after decades of clinical experience with this phenomenon of such immediate mind and body awareness of other, we now simply refer to it as exchange. A simple working definition of exchange is: The process, unconsciously and consciously, of directly feeling the physical and mental experiences of another person or group. Exchange occurs whether we are aware of it or not and whether we invite it or not.
When considering actually inviting exchange with our clients, it is natural to fear that we might somehow become completely inundated and stuck with the difficult feelings of another person. Once in that situation, perhaps we’ll have no sense of how to simply be ourselves again. As clinicians, we may have had just such experiences when working in difficult treatment processes with clients, families, or colleagues. In the contemplative psychotherapy tradition, we have come to understand that the very ways of actually inviting exchange, including the intention to do so and mindfulness practices, are also the most direct ways of letting go of that energy. Mindfulness practice includes “touching” our experiences (thoughts, feelings, bodily sensations, etc.) in as direct a way as possible. From there, we let go and come back to the freshness of being in the present. Letting go works against the tendency we have to fixate, or actually hang onto experience, whether positive or negative. And just as with any difficult thought or feeling, the act of “touching” the exchange experience allows us to have a less filtered sense of those feelings, while “letting go” provides a way of transforming or dissolving the energy (Wegela, 1996).
Before moving on to a broader discussion of exchange, we will return to the earlier point about countertransference in order to clarify how we see these phenomena in relation to one another. In some circumstances, we know that countertransference can open us to exchange. Using an obvious example, if we meet a client who has a powerful resemblance to our mother, we will tend to be activated with a spectrum of countertransference responses, which may potentiate our conscious and unconscious resonance, or exchange. But in our experience, we know countertransference as being secondary to, and often in response to, the more primary unconscious and conscious activation of exchange. Likewise, transference can also potentiate exchange, as it may create a more focused, “special,” and resonant relationship toward the therapist. And like countertransference, we observe that transference typically exists in a secondary and responsive relationship to exchange.
Most of the time exchange will manifest in the form of feeling states, moods, sometimes imagery, and possibly even thoughts. Physical changes will typically also be part of the mix, like a tightening or tingling in the stomach, or whatever it is in your body awareness that indicates an emotional or felt-sense experience is at hand. More gross and long-lasting physical symptoms can also be part of exchange: backaches, headaches, various kinds of painful body tension, fatigue, digestion issues, tactile sensations (one particular client suffered with delusory parasitosis), are all possible through exchange. Some of this can be a source of humor on the team, as once when we were working with a particular client with a severe eating disorder, many of us found ourselves craving nothing but red meat and rich food in general. One team member stated, “All I want to do is eat ice cream!” While our client steadily gained healthy ground on her undernourished condition, I know I (Chuck Knapp) was not the only team member to gain weight as well, which I really did not need to do.
The phenomenon of exchange can be easy to miss, as we often may only feel a heightened or slightly altered sense of our own energy styles and thoughts. A good deal of the time the experience will show up as one’s feeling states change while in session with a client or on a basic attendance shift, offering information about how the client may be feeling. And with everything else that is going on in a team environment, much of the time the experience of exchange may not rise to the level of actually being easy to identify. Very recently, I (CK) was meeting with a client around a life predicament that frequently arouses intense anger in him. While in session, I did not notice anything in his demeanor that indicated he was angry, and the only thing I noticed in my own mind–body awareness was feeling a bit brighter-minded and more energized than usual. But after the session, once he had left the office, I ran into a couple of colleagues in the hallway and found myself on the verge of attacking them verbally, feeling inexplicably outraged at simply seeing them. Fortunately, I caught the attack at the thought stage, so my colleagues were unaware of what was going on with me. But I was shocked and retreated to my office to get my bearings and process what I had just been through. It is not unusual in my experience that exchange will be more clearly felt after having contact with someone; sneaking up on you afterward, so to speak. And unfortunately, I can say from personal experience that if one is being unwittingly affected after the fact by difficult exchange, one has to be very careful so as to not take those feelings out on innocent friends and family.
Beyond being an element of how we experience dyadic relationships, on a Windhorse team exchange is frequently evident within our meetings and as an atmosphere for the team as a whole. Particularly with teams for clients and families who have strong and distinctive qualities, the team will often take on the family’s flavors of mind and activity. Though perhaps subtle, this experience often feels like we have become “inhabited” by the mind of this client and family.
One personal and team example of such exchange occurred when working with a particularly creative and extremely bright young woman who was also intensely willful. Though agreeing to be in a treatment with us, she had pronounced resistance to being a “compliant good girl” team member, which often resulted in conflict between her and the clinicians. Every time I (CK) was involved with her directly, or was in a meeting about her, it felt like my IQ shot up, as did my creativity. That was the fun part. The other pronounced side of the exchange was that, for the two years the team was in place, we reflexively and unreasonably tried to control her, as she did us. Recognizing this pattern and knowing that we were vulnerable to repeating it in gross and subtle ways, over time we were able to catch ourselves progressively earlier in the process. Eventually we usually recognized the urges toward unreasonable control in their subtle forms and managed to resist going into action to make her do something that “would be good for her.” The end result was that she was able to functionally emancipate from the real and imagined control of her family (including the team as a transferential family) and to take effective responsibility for her health and independence. Our relationship, which at times in the beginning felt like a “fight to the death,” ended with her feeling like she was ready to move on from the lifelong conflict with her family. She also felt like she won the fight with us, a sense that was completely shared by the team.
At Windhorse, we avoid solidifying these kinds of experiences into overly concrete conceptions of the client’s mind. We know that the phenomenon of exchange is ephemeral and fluid, but, as in the example above, it frequently offers valuable insight for the treatment process. It also invariably helps with generating compassion for the client’s experience, as it offers us glimpses of what it is like to be in the other’s world.
In describing another dimension of this phenomenon, Podvoll says: “Especially at team meetings, where everyone is present, different team members will exchange with a different aspect of the patient, including aspects of the patient’s sanity and intelligence. Thus, they are able to represent him or help him speak. In the team situation, the exchange becomes more complete and multidimensional” (Podvoll, 2003, 271). With different aspects of the client’s mind being experienced through exchange by the various team members, sanity and intelligence will be felt more by some than others. At the same time, difficult-to-tolerate feelings will also be felt by some team members more than others. Naturally, with this being the case these variations in exchange can show up as interpersonal tensions and polarities between the team members, as the following example shows.
This is a story that occurred in a long-term team that had been underway for about twelve years at that point. The client was going through a period of unusual growth, exploring new life activities that he had previously avoided. At the same time, I (CK) was having extremely aggressive feelings toward another team member, an old friend and trusted colleague. As a clinical team, when we would discuss how to support the client in his explorations, my colleague would be a conservative voice counseling to go slowly—“not to set him up for failure.” I was a strong voice for us doing all we could to help him grow, knowing that he would make mistakes along the way, but that we could help him learn and grow from those experiences. After several weeks I found myself not wanting to even look at my old friend, the conservative clinician. I felt intense hatred toward her and complete repulsion. I wanted her off the team. During a meeting when the opportunity seemed right, I brought up my feelings. To my surprise, she had been having exactly the same feelings about me. What we realized was that, instead of either of us being completely incompetent clinicians who should no longer remain on the team, we were exchanging with the progressive and regressive polarities of the client’s mind. Once we realized this, we were able to relax. The intensity of the feelings lessened and became valuable information. We also were stunned and heartbroken by the murderous intensity of the struggle that our client was experiencing between his progressive and regressive impulses.
As demonstrated in this last example, we cannot overstate the importance of recognizing the non-solidity and transparency of one’s thoughts and feelings within our individual experience, as well as within the general mind atmosphere of the team. Otherwise, treatment-destructive sub-grouping and polarities can become problematic, instead of being understood as an aspect of the mind of the situation and as tensions that will naturally be present. As this previous example also showed, a heated staff conflict may be misinterpreted as simply being between clinicians who are not getting along. Prior relationship dynamics can certainly be at play in such exchange tensions, as pre-existing relationship problems of various kinds can make certain people in the team highly susceptible to absorbing particular kinds of emotional energy. For instance, in the previous example, the woman clinician and I, though very good friends, were the most outwardly aggressive people on the team and we had a history of periodic difficult conflict. Seeing us at odds was not new for anyone. But when such conflict arises on a team, we deliberately explore in order to understand if exchange is part of the mix, as it frequently is. In this way, such experience provides deeper insight into the nature of the team environment and how we may be vulnerable to acting out the client’s and family’s predicaments.
The examples used throughout this paper will touch on three basic emotional styles that occur within and in response to exchange: aggression, passion, and ignorance. So far we have looked at problematic examples of aggression as they have resulted in either conflict or control. We understand the fundamental therapeutic error of aggression as being one in which we are forcing our idea of a cure on someone, whether he or she wants it or not. The presence of the neurotic side of passion (another term for grasping over-attachment) in a treatment setting will frequently cause problems with the clinicians becoming overly invested in rescuing the client and family. The presence of neurotic ignorance in the treatment setting will cause the clinician to miss that the therapeutic interaction is actually a mutual relationship in which both the client and therapist are deeply affected and vulnerable to how the treatment unfolds. “Whoever you are working with, is also working with you,” and that “the failure to acknowledge that, the failure to respect that, the failure to be appreciative of that is the major single cause of neurotic countertransference. The ignorance of that leads one to become ever more increasingly professional” (Podvoll, 1986, Talk 1, 6). Professionalism in this case describes a cut-off from allowing oneself to actually be present as a human being in the context of a very human relationship. It is also antithetical to the process of mutual recovery.
◈ Suicidality and Exchange
It is not within the scope of this paper to detail all the ways we’ve experienced exchange at both the individual and team level. However, one obviously critical area of awareness in which our experiences of exchange have been extremely helpful, is around the suicidal impulses of the client. The first time this became apparent to me was many years ago on a team for a young woman who was suffering with a combination of deadly disorders, one of which was rapid cycling moods. These included spikes into depression with strong urges to kill herself, which could be exacerbated by her binge-style poly-substance abuse. Fortunately for her, she was living with a very sensitive and self-aware housemate.
Late one night, her housemate started having feelings that something wasn’t right in the household, so uncharacteristically, he knocked on her bedroom door to see how she was doing. She answered the door, slurring her words, saying, “tell everyone I’m sorry.” Recognizing that she was well into the process of an overdose, he immediately called 911 and the ambulance arrived just as her heart stopped. As we all know, so many of these stories don’t end well. But after spending four days in the local ICU and having no residual organ damage, she became genuinely inspired that it was not her time to die, nor was it her destiny to take her own life.
Another example of individual exchange with the client’s urges toward suicide occurred on a team where the young man, again suffering from a combination of co-occurring and synergistic problems, was developing a certainty that his life was never going to be as he wanted it to be. We also knew that he was playing with the notion that suicide could be a viable solution to his predicament. I (CK) was the team supervisor and did not spend a lot of time around him, but one day noticed that I was longing to die. Specifically, the phrase came to mind as I was daydreaming about an accident that would take my life, “Oh, now I get to die!” I recognized this as something foreign in my mind, or at least an exaggeration of my own at times mildly suicidal thoughts, and as such, likely exchange with someone. After taking stock of who might be in my midst that was suicidal, I realized it was probably this young man. I shared my experience with his therapist, who confirmed that he had just began speaking with her about how dangerous his impulses had become to kill himself.
Sometimes exchange around suicidality will show itself in more atmospheric ways. This example has become prototypical for me as it demonstrates two elements in the process of a suicide: the loss of impulse control plus the unilateral decision to leave. On this particular team, we had no idea that the young woman client had become suicidal. She was in what appeared to very strong and congruent relationships with the team, and had been making excellent and steady progress in her recovery. We also knew that she was heartbroken about having difficulties that changed her sense of herself and what she would be capable of accomplishing in her life. Her team meetings were typically pleasant and fairly relaxed, but about two years into the life of the team, when we arrived for a team meeting without her present, it became apparent that we had a crisis: Two usually very disciplined team members had engaged in some personal contact that was completely out of character. And one of them, a usually reliable person who was committed to collaborative team-work and supervision, abruptly and unilaterally decided to leave the team without speaking to anyone about it. As it was the only team he was on, he was able to effectively cut off contact with us. We were all shocked and a bit angry, but we also wondered “what got into him.” It was embarrassing and sad having to tell the young woman client about the basic attender abruptly leaving the team. But she appeared unfazed and understanding, much as if to say, sometimes people just need to move on. Then two weeks later, in a complete surprise to her family, her friends, and for her team, the young woman client was found dead from suicide. Unfortunately in retrospect, we then sadly understood the impulsivity of the team members as exchange with the client’s loss of impulse control. And the unilateral, non-collaborative decision to leave the team on the part of the basic attender, we understood as exchange with the completely secretive decision of the client to leave her life. Since then, whenever a team member begins to push impulsively to leave a team, and that does happen, we always do our best to slow the process down, talk about it, and explore if the client is having suicidal impulses, as he or she frequently is.
One last example of exchange with suicidality occurred on a team with a young woman who suffered with a severe psychosis. She would go in and out of serious urges for self-harm, but at this particular time we knew she was riding a very dangerous edge. She would often wake up in the middle of the night, which would rouse her housemates, and on this particular night, in the words of one of the housemates, "She awoke and was quite stirred up, and was in the backyard, which I assumed was to have a cigarette. But there was also a strange sense about her. I convinced her to come inside, have a PRN, at which point we returned to our rooms, presumably to go to sleep. I began composing a text to the team leader, as that was the protocol at the time when a PRN was given at night, but while doing so a very strange feeling came over me. I was alone in my room in the dark, with only the light of my phone illuminating anything, and suddenly (and very compulsively) I had the urge to hide and cover my phone so no one would see it! That stopped my mind, and I immediately knew it was not my mind. Without thinking, I sprang up, ran down the hall, and then outside. I called out the client’s name, and she slowly and silently came around the corner of the fence, away from the tree, and retreated into her room. At that point I totally panicked but was also 100% clear. I ran downstairs, awoke the other housemate, and then I had the courage to go back outside to see what the client had been doing. Then we found the chair and the noose formed from the red sheet, hanging from the tree.” We worked with this young woman for another two years, and that was the last suicide attempt she made.
◈ Exchange Impacting Team Functioning
Beyond personal experience and relationship dynamics within the treatment team, the effect of exchange can influence the overall functioning of the team. This may include, but is not limited to, the pacing of the treatment, decisions made (or not), and whether we are inclined to end a team prematurely or to keep it going too long.
The following is an example of exchange that had a pronounced effect on the general approach we took toward a young man’s treatment. After the team had been underway for about nine months, I (CK) was in a team meeting for this very strong-minded fellow and had an experience that was like waking up from a dream. My initial protective attitude toward him had seemed completely natural and correct, at least to me. But with some skillful questions from the team psychiatrist, I realized that my approach was surprisingly client-centric and imbalanced in how we had been organizing our work and relationship with the family. As the team supervisor, I had an unusually close paternal kind of relationship with him. I admired him in many ways and was touched by his remarkable and often unappreciated intelligence, vulnerabilities, and fragility. My “pre-waking-up” sense was that I wanted him to have every chance possible to explore how to be an adult on his own terms. The problem was that I was pulled much too far into his wanting protection from the reality of his life situation, and my judgment had become skewed in matters that were critical to managing the long-term sustainability of the team. Basically, my unrealistic protection of the client was unskillfully stressing the finances and patience of the parents. Fortunately, there were positive aspects of the skewed exploration, as the family appreciated me for not taking a rigid, more institutional stance with their son (as had been the case in previous therapeutic settings), and the client felt that I had gone out on a limb for him. However, a correction to better balance was clearly in order. Now, I look back with some amazement as to how far I got pulled into the exchange with this young man and how I continued to be susceptible to being blindsided by it, even while vigilantly attempting to avoid just that.
In this case, I was being pulled toward the dependence of the client. It is perhaps even easier to be pulled into unrealistic expectations for the client’s functioning and independence. This is especially the case if the family has been frustrated for a long time and now feels an urgent need for what they see as necessary and healthy change. We will say more about this later, within the section on family work.
Again, it is worth repeating that the effects of exchange may be subtle and easy to miss. But as observed by our colleague and frequent collaborator, psychologist Robert Unger, an expert in group psychotherapy, “It’s not if these types of experiences occur, it’s when” (personal communication).
◈ Split Transferences
Within teams, another layer of relational complexity occurs through transference. When an individual therapist works with a client, transference develops. When one client is working with a team of therapists, as with a Windhorse team, transferences develop with each clinician. We refer to these as split transferences, and they are specific to each clinician. Collectively, these individual split transferences comprise the whole transference field that is the team (Goldberg-Unger, 1978).
Through split transferences, clinicians may take on identifiable roles, usually family system roles. As stated earlier, split transferences can also potentiate the exchange a clinician experiences as he or she becomes a special (positive or negative) person in the client’s or family’s eye, thus focusing more energy on that relationship. The following example describes a pattern of toxic parental transference, first to me (CK) as the team supervisor, in opposition to a joined, protective transference first occupied by the psychotherapist.
Jack Gipple and I had just finished a successful team together. Our mutual trust was high, and we were looking forward to working together again. But as this new team progressed through the typical beginning-stage chaos, and as relationships started to stabilize, it became clear that Jack did not trust me in the context of this team. Once we identified the unusual feelings of distrust, we could reasonably identify the source. The client was an intense and brilliant middle-aged man, who was suffering with a paranoid psychotic process, trauma, and extremely difficult feelings toward his parents. He had tremendous fear around the role his parents had played in his life, having had periodic involuntary hospitalizations that he did not understand. Thus, being the person most closely associated with the parents, I was in a toxic-parent transference, and Jack absorbed the client’s feelings that I was highly dangerous and in no way should be trusted. His feelings also compelled him to protect the client from me. Relationally, it was a relief for Jack and me to understand where these feelings were coming from, but that did not stop them from being very strong, unpleasant, and persistent.
About six months into the treatment, the client was no longer willing to meet with Jack (there was a significant additional diagnosis and the client insisted on an expert in this field), so we decided to bring in a new therapist. As before, this therapist was a long-standing, trusted friend and colleague of mine. And as before, the same painful but now understood relationship dynamic of distrust arose between the new therapist and me.
About a year into the treatment, as the client became more confident in his ability to manage his parents and me, he no longer felt the need for us to meet. As a result, he wisely refused to do so, thus avoiding the stressful transference experiences that were particular to our relationship. However, shortly after I ceased having face-to-face contact with him, the threatening parental transference role became occupied by the new therapist. Once this shift occurred, the basic attenders and team leader began experiencing intensely distrustful and suspicious feelings toward the therapist. Our team meetings required careful process work in order to stay clear in the face of such a difficult team dynamic. Before long, the client would no longer see the new therapist, but by this time the transference pattern was predictable, and we were able to organize ourselves in a way that the parental figures were kept at a safe-enough distance. At that point, the client could relax with the basic attenders and other safe team members.
While this is a general example of split transferences in action, it also demonstrates one of the more problematic aspects of this phenomenon. When a transference is occurring in a successful treatment with a single therapist, all the elements of attachment and repulsion exist in a positive-enough balance, so that the overall experience for the client is tolerable. When split transferences occur, the positive aspects of the transferential field may land more on some clinicians than on others, and the painful, repulsive aspects will sometimes land in a more rarified form on the non-positive object clinicians; or perhaps very strongly on just one of them. Thus, the clinician who is experienced by the client as a singularly repulsive transference object may not have the benefit of the positive transferential aspects in order to retain a strong-enough attachment so that the relationship remains tolerable for the client. As a result of not being able to tolerate the split transference, the client may become inclined to “kill off” that clinician, i.e., request that he or she be removed from the team, or that the client simply refuses to see them.
How we work with the client’s urge to remove a clinician from the team has many variables. First of all, we always carefully consider if the relationship between the client and clinician is simply a poor personality fit. In that case, that clinician leaving may be a helpful adjustment in the evolution of the team. But if the relationship has been generally positive and has evolved into a problem, we then consider the following: What is the stage of treatment; how strong is the attachment/alliance between the client and the clinical portion of the team; how congruent is the therapeutic container between the clinicians and the parents; how capable is the client of integrating difficult, perhaps even unconscious aspects of her mind; and how capable is the clinician in question of tolerating being such a negative transference object. Whatever the circumstances, we are careful to consider maintaining tolerable therapeutic tension with the client and family, recognizing that, while it may be difficult to lose a valued team member (which incidentally does not enhance the feeling of safety on the team), it may be therapeutically aggressive and treatment-destructive not to follow the client’s wishes. In situations like the example above, we were never able to get beyond the dynamic where the client could not tolerate aspects of his mind, thus attempting to serially “kill off” parts of his awareness. For others, what was clinically indicated in an early stage of the team becomes a very different consideration later on, as the client’s insight, integration of awareness, resilience, and alliances have further developed. Thus, we may be able to use such an urge to reject, turning it into a valuable therapeutic process. In any case, even though the client is driving the need to let go of a team member, we clearly maintain, as part of the power of the clinical portion of the team, the right to make the actual decision to let the person go (or not). In that way, we do what we can to help insulate the client a bit from her urges to enact an aggressive act toward herself and others. And in some relatively rare instances, we may decide to end the team before getting rid of a critical team member who represents an indispensable therapeutic element for the team.
In most situations, there are ways to prevent the tension between a client and a clinician from reaching such an intolerable point. We are always on the lookout for how the therapeutic tension is balanced throughout the relationships of the team and, if it looks like a particular relationship is “overheating,” we attempt to make adjustments that will redirect the tension. For instance, it is common for a client to come to us who has had difficult experiences around medications with their psychiatrist. And it may be that the client really needs to be on medications in order to develop and maintain more stability of mind. If somehow the onus is put on the psychiatrist to not only explore how to optimize the use of medications but also to communicate the need, or possibly the programmatic requirement, to be on them, that will naturally bring more negative focus on that relationship than it may be able to bear. In that situation, we can redirect the pressure to remain on the medications toward the team supervisor. Then the psychiatrist, who in many teams is in a completely critical role, is freed up to be an ally as opposed to being perceived as a jailer. The same kind of strategic move can be implemented if, for instance, the team leader is becoming too much of a negative focus for the client, due to organizing chores around the house that she finds difficult. In that situation, we can shift some of the organizational focus onto the assistant team leader, or on a basic attender with whom the client may have a strong relationship. Or again, the team supervisor can be blamed for making the team do all this housework.
◈ Predictable Transference Roles
The various Windhorse team roles are predisposed to certain kinds of transference. Transference to the team supervisor is frequently parental, as we are older clinicians and have overall responsibility for the process of the treatment. Team supervisors are also the primary contact with the family, as will be discussed later.
Likewise, transference to the psychotherapist is typically parental, but generally a safer version than the team supervisor. The following example illustrates a situation in which these typical transference roles were reversed—the team supervisor was the safe parent and the psychotherapist was clearly dangerous.
Our client was a young woman who, while working with her primary mood and life adjustment issues, was clearly in a hostile though submissive relationship with her mother. In her mind, her mother was both God and the enemy, a person to admire and fear. She had never been able to speak openly with her mother, especially about how angry, hurt, and humiliated the relationship made her feel. Once we came out of the early stage of developing the team, our client showed clear transferences to me (CK) as the team supervisor and to the female psychotherapist, Mary. Mary’s role quickly became one in which she felt utterly worthless. The client would cancel appointments, having odd reasons for not seeing her. The client was a highly intelligent young woman who could express herself in an exquisitely disdainful manner. She quickly showed her skill in making Mary feel like an utterly incompetent therapist. Our client had had a lot of psychotherapy in her life and, without question, she let Mary know that she was a lousy therapist—by far the worst she had ever known, even reprehensible, and insulting to spend time with. Being with Mary was “glorified and expensive babysitting.” On the other hand, the client’s father was a safe and admired person in her life. I became that person to her on the team. It is not usually the case that a team supervisor will do regular therapy-style sessions with the client, but in this situation it became necessary in order to regulate the therapeutic tension between her and Mary.
For approximately the first year and a half of treatment, it was Mary’s job to tolerate (without being abused) how it felt to be with the client and to make it safe enough for the client to tolerate her. We could see that the client was expressing both how it felt to be herself (loathsomely incompetent, dishonest, not worthy of love), and what she wanted to say to her mother, hoping to make her mother feel incompetent and not worthy of feeling good about herself in any way.
As difficult as it was, Mary was excellent at tolerating these experiences, knowing they were a combination of transference and potent exchange. I was able to spend enough time with the client, helping her blow off steam about how difficult and punitive it felt to spend time with Mary, as well as helping her feel safe when she attended team meetings with Mary present. After the team was about a year and a half old and the client was feeling more stable and competent in the world, she gradually became fond and even admiring of Mary. This shift was accompanied by a mutual but guarded relaxation in the relationship with her mother. While they never actually spoke in a completely open way about their respective painful feelings, it was wonderful to see the mother and the client become respectful of each other, both of them knowing that without care the relationship could devolve into the habitual patterns that had caused each of them so much suffering.
Regarding the kind of client–parent transference just described, and the resulting extremely difficult feelings for the therapist, Harold Searles noted, “More than once I have felt close to psychosis in trying to cope with intense and simultaneous feelings of rage, hurt, sexual desire, grief, and so on which a deeply psychotic patient was arousing in me. All this was evoked in the context of the patient’s powerful and tenacious transference to the therapist as being the crazy—whether openly or covertly—mother or father of the patient’s childhood” (Searles, 1979, 97).
A common pattern in the complementary functioning between the team supervisor and the other team roles is that the team supervisor will hold a position of setting necessary boundaries that will likely be challenging for the client. If possible, it is helpful if the psychotherapist can avoid authority-figure boundary setting. Thus, he or she is freed up to help the client work with the more subtle elements of her mind and relationship issues with the other team members. We also try to keep high relational tension away from the team leader. The team leader is likely to already have significant tension built into that role’s activity, and may spend up to eight hours per week with the client, between basic attendance shifts and meetings. The team supervisor is typically further away from the day-to-day functioning of the client’s world and is not as involved in the regular schedule of contact as the team leader and psychotherapist. At that distance, the team supervisor is therefore in a good position to have anger and difficult tension directed at him or her without disrupting the functioning of the team.
◈ Other Team Roles and Transferences
The team leader transference can have parental elements, but is often related to by the client as a more functional sibling. As described earlier, the team leader’s role includes coordination of the household, schedule, and basic attendance activity, all essential to making the team function in a synchronized manner. Optimally, this can provide a positive role model for how to function and develop as an organized and responsible person. However, another potential for the “more functional sibling” transference is that, to the degree the client is unable to care for herself in life, to that degree there may be projections of self-aggression around not being able to function as she and/or the world expects. The client’s externalizing of the hostility that she has toward her own less-than-functional/inadequate internal team leader can produce relentless conflict in the relationship between the client and the actual team leader. Another potentially difficult manifestation of the more-functional sibling transference is that the client may expect, and actually feel, a familiar and painful repetition as other team members and her parents develop “better” and more functional relationships with the team leader than with her; basically, in her mind, liking and working better with the team leader.
The client’s transference with a basic attender is usually as a peer or sibling. It is worth repeating that this style of dyadic therapeutic engagement occurs within the broad environment of the client’s life and for longer periods of time (usually two or three hours) than of typical psychotherapy. During these contacts, the client and basic attender may be involved in a wide variety of activity, ranging from ordinary domestic responsibilities to any kind of engagement out of the home, such as exercise, artistic interests, educational activity, or pursuing employment. The setting for this contact is in the household and community, with precise but fluid boundaries, exploring and engaging the world with one’s full being: health, confusion, and interest, whatever is there. As the basic attender–client relationship evolves in this way, the most common tendency is for the relationship to form as a friendship. These people really get to know each other, so much so that we have a term—therapist-friend—that acknowledges this genuine and earthy aspect of the relationship.
Transference to the housemate is often a more vivid version of the basic attender peer–sibling transference, and what was described above about friendship especially applies. Given how closeness may naturally develop when people live together, and given that the client may have a powerful secret world, the housemate may tend to get pulled into a relational allegiance that can create separation from the rest of the team. As supervisor of the housemate, it is important that the team leader is vigilant around such secretiveness or split, as it could result in a lack of full engagement with the team.
The following description includes a relatively common storyline within a moderately evolved split. Knowing the client and household much more intimately than the rest of the clinical staff, the therapeutic housemates in this particular team would see how we (the outer team) would miss details in the house, possibly leaving a mess behind us, and how we could be hoodwinked and manipulated due to simply not being aware of what was really going on with the client. On the other hand, from the perspective of the outer team, the housemates generally looked unusually intense, edgy, and prone to strong emotional reactions to us. In its extreme expression, to the housemates, the team looked “stupid,” and to the outer team, the housemates looked “crazy.” Beyond the more obvious question of why the housemates perceived the outer team as out of touch, and why the outer team saw the housemates as emotionally challenging, we came to recognize that exchange played a role in this fierce and mutually negative perception. We realized that the housemates were picking up the feelings of the client; she experienced the outer team as not being tuned into who she really was and how she thought about things. She felt unseen a lot of the time, and that we were ignoring her, preferring to stay in the comfort of our own safer, professional world. For the outer team, our perception that the housemates were “crazy” spoke to our resentment toward the client for not changing in the ways that we wanted.
Because the client and housemate share a home, there is a high likelihood of potent transference and exchange. When this is predominantly positive, it not only produces a highly informative window into the client’s world, but also a profoundly therapeutic relationship within the team. Regardless of whether the relationship with the client is predominantly positive or negative, housemates are especially vulnerable to experiencing unexpressed emotions that may not be in the client’s awareness. Because of this, we always pay very close attention to the words and feelings of the housemate.
As with any of the team members, strong exchange for the housemates may lead to an exaggeration of their natural style of neurosis and defenses. For example, with a long-term client who has a powerful ability to cut off awareness and ignore, it is a predictable pattern that, once a housemate has been with her for a little while, we will see the housemate begin to have new or intensified “ignorance practices.” One such common practice is that the housemate will begin zoning out on television in a way that is an exaggeration of what he or she may have previously done. With this kind of heightening being a general pattern in households, we do our best to keep an open supervisory dialogue with housemates around using this living experience for intensified learning around one’s own mind. Part of that is also helping them to develop disciplines that can provide grounding in healthy and wakeful life practices.
◈ Exchange and Recovery
Fortunately for the recovery process, exchange goes both ways.
One’s emotional experiences, as well as instant mental dramas and body sensations, are often found to be exactly what are missing from the patient’s own expression, as if split off from the patient’s awareness and experienced only by the therapist. Certainly it also happens in the other direction. This is one sign of the continual ebb and flow of interpenetrating exchange between therapist and patient, and among people in general. (Podvoll, 2003, 329)
Through exchange, we feel the client and family; they exchange and feel us as well. It is not unusual that our clients will have years’ worth of experiences with each clinician on the team as we go in and out of various kinds of emotional states. The client will exchange with us within the full range of life in the team, some of which is clearly challenging. In the more difficult range of emotional life, they will exchange with us as we become angry, frustrated, dumbfounded, confused, self-aggressive, and, very importantly, as we respond to making mistakes in general and with them in particular. Some of our best and most therapeutic work happens around challenging emotions and mistakes. Can we be vulnerable and acknowledge a mistake? Do we beat ourselves up? Do we beat ourselves up for beating ourselves up? Can we give up the arrogance and professional power differential within the clinician role at this vulnerable point, in order to be in a genuine relationship with the client and acknowledge an error? Can we let go of difficult and intense states of mind? To the degree that the clinician is able to practice non-attachment to his own difficult states of mind, and to bring maitri (healthy self-love and acceptance) to these kinds of experiences, the client will have the opportunity to exchange with a fresh way of lightening up and accepting oneself as simply human; making mistakes and having challenging emotional experiences because we are not bad, but human.
Critically, the client is also exchanging with the healthy, more cheerful aspects of the team’s individual and collective mind. Good life rhythms, more developed impulse control, capacity to self-soothe, organized thought processes, tolerance of being in the present, stability of mind, letting go of intense mind states that we may be overly attached or averse to, allegiance to sanity, discipline, humor, windhorse, and maitri are among some of the positive aspects of what a Windhorse client will exchange with as a member of the team. Exchange in this way becomes a powerful part of our mutual connection to intrinsic sanity, and it becomes a significant element in the team’s invitation toward a higher level of functioning.
Beyond exchange between the individual client and a team member, what follows is an example of the client responding to a general change within the basic attenders.
We had been working for a few months with a young woman who was highly anxious. Part of how her anxiety manifested was that she had difficulty managing the contact with us, and she rarely wanted to leave her home. I (CK) also could see that the basic attenders on the team were feeling the need to get her to do something, almost anything, in order to feel like they were being helpful. At some point it became clear that these clinicians were feeling quite anxious themselves, and their way of working with it was to attempt to create what they thought would be healthy change. However, in the face of that, the anxious client was retreating further. Being around the basic attenders frequently made her more anxious, even with nothing going on, and this was made worse when she felt the need to exert protection and control in the pacing of her relational engagement and activity. When we finally recognized and worked with the anxiety that was being held by the team, this created genuine relaxation for the basic attenders. They were then able to refrain from pressuring the client in subtle or gross ways to come out of her comfort zone, and from possibly exacerbating her anxiety with ours. As a result, the client was noticeably able to relax as we relaxed, and move toward more engaged relationships with the team, even gingerly risking going out of her home.
Implied in this previous example is the potency of exchange that can occur from not just one clinician on the team learning to adopt a different behavior or attitude (in this case learning to relax), but from a group of clinicians making such a change.
Another profound effect of the presence of the full team occurs when the client is in a team meeting with all clinicians present. Most of the client’s experience of the relationships on the team, thus of the split transferences and exchange, is within the dyadic basic attendance shifts and therapy sessions. But when everyone is together as a group, the complete presence of the client’s mind is in the room. As mentioned above, at first this may not be such an easy experience for someone who is not familiar with the full range of his mind. But over time, the alternation of experience between the dyadic basic attendance shifts and coming together as a welcomed and safe-feeling member of the group with the full team present offers the client an opportunity to form a progressively more integrated, familiar, and accepted sense of self.
◈ Inviting Exchange
Given the various benefits of exchange and split transferences, we intentionally set up teams in a way that will encourage such potent and whole person engagement. This is one element of the specific tailoring of the team to a client and family. Aside from the skills required for a particular client’s issues, we bring a team together considering the age and gender of the client and which clinicians we think would be most compatible. Beyond that, we select team members based on who has common interests with the client; passions or disciplines such as art, music, outdoor activities, cooking, writing, and so on, all of which can further foster relationship, engagement in life, thus inviting genuine relationship and exchange.
◈ Summary
Within the relational complexity of a team environment, exchange and split transferences can manifest in very subtle as well as surprisingly intense forms. Either way, they carry the potential of producing both confusion and awareness. Likewise, at a very basic level, we know that what appears to be confused energy with our clients and families contains deep elements of sanity (Trungpa, 2003). By understanding the subtle elements of mind and team processes through exchange, split transferences, and group dynamics, we are more able to avoid simplistically seeing a client and family as just ill. With this more accurate kind of attunement, it is easier to access our compassion and to see the subtle humanity, fear, loneliness, creativity, strength, and intelligence working within these initially confused patterns.
Section III—Team as External Ego
When a group of people intentionally arrange into a treatment team, the multiple overlapping levels of exchange form a supportive web. The team can be seen as lending external ego strength to the client and to the family system. Once the team is established, the many relationships a client has within the team form an external ego structure that supports the client’s impaired ego functioning. Through the client’s exchange with the team members, the client is able to function at a higher level than he or she had achieved before the assembly of the team. Inevitably, the initial structure of the team is not entirely accurate. During the formation process of the team we adjust the precise form of the team to better tailor the team to the client. This adjusting continues for the entire life of the team, initially to be accurate to the client as he or she begins treatment, and over time to be accurate to the changing needs of the client. A large developed team will often reduce drastically in the first several months as the client develops internal ego strength. A good indicator of this internalized ego strength is an urge to connect to the local community outside of the team, through volunteer work, employment, school, religious organizations, or organized sports. Often there is a period of talking and planning for these activities before the client has the ego strength to initiate and sustain these activities.
The client borrows different categories of ego strength from the different kinds of people on the team, and also from the different roles these people hold. The housemate has influence by living with the client, supporting an environment in the house that is kind, ordered, scheduled, and rhythmic. Basic attenders spend more focused time with the client, often focusing on tasks of maintaining the therapeutic household or beginning to make connections to the community outside of the team. With basic attenders, the client has relationships with a variety of different types of people, and different relationships to each, to accomplish different kinds of things in the world. Often the different basic attenders have varied specialties—food shopping, volunteering, swimming classes—and the basic attender relationships allow clients to accomplish tasks that would be impossible without the support of the external team structure.
Team leaders are the embodiment of communication channels and team scheduling. They are responsible for the executive functioning of the team system. The team leader facilitates the group meetings the client attends—the house meeting with the housemate and a team meeting with the entire team. The team leader has the job of helping the client accomplish the tasks of living and coordinates all of the specialties the basic attenders provide. For example, a team leader may ask basic attenders to involve the client in shared responsibility for food shopping or vacuuming every week during their shifts.
The psychotherapist attends to and listens to the subtle inner life of the client. This is an important dimension of developing ego strength. The therapist lends confidence to the client’s neglected and confused inner resources. Just as the basic attenders help clients do things in their outer world that would be impossible alone, the therapist helps the client feel, remember, and imagine things that would be impossible to tolerate alone. The psychotherapist also helps the client reflect on split transferences with the team members, so that over time the client is able to integrate different feelings for team members. The therapist is especially watchful within the team for feelings developing within the team, and the therapist considers how the client’s family constellation is reforming within the group dynamics of the team.
The team supervisor helps the client, family, and other team members have confidence that recovery is happening and is possible. The team supervisor balances the therapeutic tension within the team, with a special eye on the tensions the parents hold. Parents are working with their historic view of their child, with the financial cost of the treatment, and with their own wishes to shape and advise the structure and functioning of the team. Sometimes the team is balanced and working well, but the parents pressure the client to work harder. The team supervisor both keeps the parental pressure from damaging the therapeutic community of the team and brings the pressures of the parents into the team. Commonly the family develops feelings about elements of the team that are similar to how they have related to their child who is in treatment. The team supervisor needs to watch for treatment-destructive urges from the family toward the client and toward the team against which the client is unprepared to defend.
For example, I (Jack Gipple) am currently team supervisor of a team where the parents are bringing pressure on their 25-year-old son to find employment or volunteer work, when he is still trying to stabilize on medications for extreme bi-polar disorder that has only recently been accurately diagnosed. The son is unable to defend against the parents’ destructive pressure without repeating long-standing patterns of interaction between them. As team supervisor, I am pacing the parental expectation so that it does not destroy the team’s and their son’s progress. The parents do not agree with each other on their son’s abilities, and their long-standing ambivalence over their son stimulates the team in treatment-destructive ways. As the team supervisor, I talk with the parents weekly to help them understand how their feelings disrupt their son’s efforts toward independence and recovery. If he had a stronger ego, my client would try to do this for himself. My actions help to reinforce his weakened ego, so he learns to protect himself against destructive intrusions by authorities in his future. In this way the supervisor lends confidence and credibility to the entire team’s structure and to the possibilities of ego strength that the client can come to over time.
A typical Windhorse team develops over time along the same lines observed in more conventional groups. Typically in early stages, the client feels and thinks of the team members as practically interchangeable people—equally appreciated, equally disliked, equally indifferent. Then differences between people emerge, and the client develops split transferences with team members. Some team members are experienced as more harsh, some are kinder, smarter, or stranger. In this period the client may insist that a person leave the team, out of either intolerable disdain or attraction.
Over time the client learns the individual differences between team members. The client learns their different roles and the purpose of different group meetings of the team. The client’s growing ability to discern the right people and settings to bring different issues to light mirrors the restructuring of his own inner world. Strong feelings about the temperature of the house go to the house meetings. Wishes to change the team schedule go to the team meeting. Disturbing memories and urges go to the psychotherapist. Demands about access to money end up in the family session.
Eventually, an appreciation and feeling of really being known and seen permeates the entire team. In my experience, teams that stay together over a year start to feel like an extended family to all of the team members, even extending to the client’s parents and larger family. A trust and shared history develop. While the members of the team are able to stay in relationship and appreciation, they are also seen as quite different from each other. When a team stays together long enough to get to this point, the different levels of ego support, which felt separate and fragmented at the beginning of the team, are integrated into a more cohesive ego structure.
Team meetings can be a powerful group setting in which this integration happens for the client. Two teams I (JG) am currently working on have clients facilitating the team meetings, assisted by the team leader’s coaching, as needed. Client facilitation of team meetings is typically the beginning of the end of a team. Teams generally last six months to two years. Occasionally teams last two to five years, when client and family are dealing with complex interlinking issues, such as when the team is helping the client through a developmental phase. Through the unique relationships with other team members, clients also take the strength, which at first was modeled or lent, into themselves, integrating into their internal ego structure what at first seemed externally applied, artificial, and forced. The client at this point is engaged more in the world beyond the Windhorse team—with work, school, friends, and creative interests. Ideally, a Windhorse team comes to an end when the client is too busy to keep up with the team schedule. The team is displaced by healthy integrated activities. The basic attenders leave the team one by one with proper goodbyes. The housemate contract ends, and the client finds an ordinary housemate to live with or is able to live independently with only occasional meetings with the team leader. In the end, the external ego structure of a Windhorse team is internalized by the client and also by the family. Often the meeting structures and habits of communication from the team are incorporated into the culture of the client’s family.
Section IV—Supervision and the Integration of Family Work
Following the overview process observations about the life of a team, we will once again dive into some details about supervision and family work.
With its many moving parts, robust supervision is critical in order to keep a Windhorse team breathing relatively fresh air. Given that we work in a relationally open way with people who are often in extreme mental states, it is imperative that we are vigilant around supervision and team health.
In our teams, supervision is an integrated and functional part of the environment, not done from the outside looking in. Our complementary roles, at different distances from the client and family, produce varied experiences of exchange, the functioning of the team, and of the recovery process. These varying perspectives tend to differentiate and express multifaceted aspects of the intelligence available within the environment. We know the team process to be an individual and group-learning event, studied from each person’s particular perspective. Within this, each clinician, regardless of training, experience, or role, at any given time will contribute critical intelligence to the recovery process. And as with any group, when properly run a team is always a great deal more intelligent than any individual member.
To repeat an important theme: A basic Windhorse principle is that we endeavor to function as a healthy and sustainable system, supporting the well-being and mutual recovery of all who are involved within the environment. We take care through the initial assessment that the design of the team will provide proper levels of structure and communication so as to be up to the task at hand. As leaders, we attempt to model respect and good communication, honoring each clinician’s unique role. We attempt to make space for all team members to speak and contribute. We listen carefully, cultivating curiosity about each other’s experience, and we encourage team members to take risks with honest communication. We share power as much as possible, attempting to always bear in mind the stifling effect that power differentials can have on a free and safe flow of communication. Leaders teach and guide as needed, doing our best to show how this is done. Leadership watches for critical recovery transitions, dangers, and opportunities to provide perspective, while encouraging team members to develop their own sense of intelligence and functioning within their respective roles. We also understand the importance of having a sense of playfulness whenever possible; humor and a bit of fun in our work is a wakeful and powerful antidote to the weariness of mind that can tend to settle in with the ruggedness of the recovery path and some of the exchange that may be at hand.
As individuals, at any given time we may take on more stress than we normally would as an individual therapist. This experience will vary from clinician to clinician, depending on how much focus comes their way through their role, exchange, transferences, and his or her vulnerabilities. Given the potential for heightened and stressful experience, it is critical that each clinician is properly connected to, and integrated with, the team. Connection and support happen primarily through our system of meetings, and individual supervision also occurs as needed. Through strong attachment to the team, each clinician has access to the collective intelligence and capacity of the group to absorb, understand, and disperse emotional energy. This makes it more possible for each member to function within a tolerable range of stress in the face of what can at times be high levels of intensity. Below is an example of a short-lived but instructive experience of inadequate connection to the team process.
The setting was a special team meeting for a woman client with whom we had worked on and off for about fifteen years. The client was a good-hearted, wonderfully expressive person, also highly sensitive, mildly psychotic, and with strong abandonment issues. Besides the client, the team meeting consisted of a woman team leader, the psychotherapist, also a woman, and me (CK) as the team supervisor. The occasion for the meeting was that, after about six years of working together, the psychotherapist was leaving the team. After much excellent work together, we wanted to celebrate the work and have a proper farewell.
While the women in the group were having a cheerful, warm, and relatively celebratory process, as instructed by the client I was “holding space.” As such, my role was to provide silent awareness, which was in almost comical contrast to what the others were doing, as very early in the meeting I began experiencing difficult chest pains. I am sensitive to exchange and, as mentioned, at times this may be felt physically. I knew from past experience that, when in the presence of someone who is feeling intense rage and heartbreak, I will sometimes have an experience of uncomfortable heart–chest pain. The first time it happened I almost went to an emergency room, but immediately I had a physical examination and stress test just to make sure I wasn’t having serious heart problems (everything was OK). Knowing our client the way I did, it was clear that this ending was deeply distressing for her, even though it appeared that neither she nor anyone else was letting the pain into their shared awareness.
After about thirty minutes, the client left the meeting in order to retrieve something from her car. I was then able to speak to the other members of the group, letting them know that while they were having a celebration, based on my experience (“I feel like I’m dying over here”), I was sure our client was suffering tremendously with the therapist’s departure. After that, we knew it would be helpful if we could at least touch lightly on the painful aspects of this ending. As soon as I was able to say this, and it was clearly heard by the other team members, my physical symptoms immediately and completely vanished. We resumed the meeting once the client came back, and incorporated the awareness of loss (without revealing my chest pains) into the team process. The client was greatly relieved to be able to say something about the loss, cry a bit, and have a much more complete face-to-face ending with her beloved therapist.
When our supervision is not adequate to the situation, which is usually obvious to identify and frequently correctable, or if a clinician does not stay in sufficient contact with the team, it can result in unnecessary suffering on the part of that team member. This can produce persistent and unhealthy levels of stress, troubling dreams, intensified emotional pain due to exchange (sometimes resulting in taking out feelings on personal relationships), splitting with the group in some way, and having difficulty tolerating or being tolerated by the client. Beyond being difficult for the clinician, such persistent problems may result in the inability for the clinician to stay on the team or even to continue with Windhorse work altogether.
In Section II we discussed how exchange is generally experienced differently by each member of the team. This recognition actually corresponds to a clinical supervision form that evolved at Naropa University in the 1970s. In this form, the body (physical), speech (emotional/relational), and mind (mental/spiritual) of the client are described by the presenter with a minimum of interpretation. This occurs within a supervision group who holds an attitude of curiosity about the world of the person being presented and the presenter’s relationship to that world. Creating a less subjective, less conceptually filtered presentation of the client, a fuller presence of the client’s energy is brought into the group supervision space. Within that, it is common for members of the supervision group to experience aspects of the client’s mind that may not have been expressed by the presenter (Walker, 2008). With a similar intention of inviting the whole client into the room, one of our often-used practices in team meetings is that at the beginning of the meeting, in this case without the client present, every member of the team does a “check-in,” presenting their contact with the client and family over the period since the last meeting. These check-ins are brief, usually only two to three minutes long, typically focusing on qualities of relationship, exchange, personal difficulty, and significant activity that may describe change; motion toward or away from health, perhaps painful experience—whatever seems important to say. From that ground in the meeting, our work with the agenda, decisions that may need to be made, and process observations will be done in an atmosphere where the exchange with each team member is present. In that way, the energy of the full spectrum of the client’s body, speech, and mind is more present. We find that this provides a more broadly attuned, whole person sense of the client, family, and clinicians, which tends to provide balanced awareness as we conduct our meetings and supervision.
◈ Family Work
Describing a particularly convoluted and intense family treatment in an inpatient setting, Searles observed, “One felt that this whole unembrace-ably vast vortex was less a team, or even a collection, of separate human individuals than a giant unicellular organism which threatened to engulf any individual who came into contact with it” (Searles, 1979, 90). There are times that a full team, that is, the group that includes the client, family, and clinicians, can feel a bit this way, even with all of our ways of understanding and structuring them along healthful lines.
Windhorse work with families is closely related to our integrated, functional supervision and how we create the culture of the therapeutic team. Many of the principles of leadership, communication, respect, and empowerment for each clinician that we cultivate in the team are common to healthy family systems. This provides a natural foundation of practiced relationship and communication norms, into which the family and client will be integrated. And, as discussed, the range of team roles also provides a palette of transference possibilities onto which the client may create a facsimile of family experience.
From the parent’s perspective, Windhorse family work usually does not resemble traditional family therapy. Co-parenting might be a closer description for this experience, but, as with all of our teams, it is quite varied in how it looks. A lot depends on the degree of dependence between the son or daughter and parents, and how much capacity the family has for clear communication. With the family, we attempt to think things through together, reviewing what has worked in the past and what has not, asking questions that cultivate insight and curiosity, and doing our best to model healthy ways of being in relationship. Usually, we are invited by the family to initiate change and to model other ways to be together. Almost always we are modeling, whether we are invited to or not. As an element of our co-parenting that was described in the section on exchange and split transferences, the team leadership is often doing family work with the client through how we serve as parental presences (and transference objects) for her. Whatever form the work takes, from the beginning to the end of the team, we are helping the family understand what recovery may look like for them, and what is an appropriate vision and timeline for that process.
Fortunately, we frequently have excellent and congruent working partnerships with parents. A significant factor in creating a positive initial phase is that by the time we begin a team, the family will understand that Windhorse is a relatively unusual therapeutic approach and that “difference” is part of what attracted them to us in the first place. That kind of buy-in is invaluable. And of course, within any healthy recovery process, tensions will invariably come and go, developing over time a sense of workability and trust as they are successfully resolved. We are learning from them as we get stuck in familiar patterns. They are learning from us about how to get creatively unstuck from those less-than-useful repetitions. A significant point is that, just as we want the client to feel like she has trusted allies in her life on the team, we want the parents to enter into genuine relationships and a trusted alliance with us as well.
◈ Contact Between Parents and Team
Beyond the agreed-upon frequency and type of contact with their son or daughter that we establish at the outset, we also define how a family may interact with the clinical team. The team leader’s family interactions will primarily be around logistics, staying clear of more therapeutic and recovery oriented discussions. The psychotherapist may have a good deal of contact with the family, almost all of which will be in the context of a family meeting, possibly a team meeting, and nearly always with the client present. The family meetings usually include the client, parents, therapist, and team supervisor. Parents will also sometimes attend team meetings. For parents who live out of town, the family meetings typically occur via telephone other than when they are visiting. Generally, the primary clinical contact for the family is the team supervisor, who will closely attend the various ways that the recovery process will manifest for them, including maintaining a tolerable range of therapeutic tension.
Considering the many possibilities of contact that a family could have with the team, what we are describing is intentionally simple and predictable. The team supervisor has comprehensive responsibility for the overall functioning of the team process, including the financial arrangements. As such, he or she is the most functionally resonant person to engage the parents. And as mentioned, we have also found that focusing the family’s therapeutic contact toward the team supervisor helps to simplify the psychotherapist’s relationship with the client.
Parents can sometimes attempt to, or accidentally, go around the team leadership contact agreement in order to talk individually with housemates or the basic attenders. Given how much time the clients spend within these relationships, it is easy to see how the parents would be curious to speak with them. However, housemates or basic attenders can quickly get induced into the overt and subtle parental emotional landscape. On the level of exchange and transference, the housemates and basic attenders are in one form or another usually joining at more of a peer-sibling level with the client. As such, they will have a high level of sensitivity to feeling the love, fear, anger, authority, and pressure of the parents to enact changes in their son or daughter.
Instead of the relationship existing and evolving in its more natural fashion, the addition of parental influence may create an increased sense of pressure that the client needs to change in ways that are characteristic of the parent’s agenda. Suddenly, what was once a safe relationship between the client and (for instance) a housemate, now has the added energetic of parental pressure and needs. There are many variations on how family interactions with the team can go off track and create relationship setbacks with basic attenders, housemates, and team leaders, but generally if the family has contact in a disorganized way, too many confusing dynamics occur.
◈ A Visualization of Health
Though the object of this discussion is to look at group dynamics within teams, as opposed to creating a detailed look at the elements of our family work, it will be useful to say a bit more about what we are trying to accomplish in these early stages of the team.
In the beginning of our teams we attempt to create a clear conceptual framework in order to help the family understand what we are all about to do. This includes helping them understand the basic view of how we work, knowing how the team process may unfold, keeping in frequent contact so that they can understand what their son or daughter is going through (which may include a fair amount of complaining about us to the parents), and helping all of us to have common guidelines for how we understand the family’s role. As part of the positive frame of reference, we have our families read the Windhorse Guide to Families. Co-written by the parent of a Windhorse client and a former client who now works as a peer therapist, this beautifully-written short paper describes how a family can be in relationship in ways that enhance everyone’s health, particularly when recovery from extreme mental states is part of the equation. The guide points to the following: 1) choosing to have good boundaries with proper relational distance; 2) cultivating attitudes of respect and acceptance; 3) choosing a positive attitude within our relationships, 4) cultivating honest communication, including appreciation; and 5) that all family members will expand their community for greater support beyond what the nuclear family can offer (Packard & Stark, 1995). Reading these guidelines is often inspiring for families, as they describe a fresh framework for healthy relations that will promote recovery. Some elements of the guidelines may be well known and part of the family’s experience before coming to Windhorse. But some of them may be unfamiliar and feel impossible to embrace, given what the family’s life has been like. The point is, by having a set of mutual reference points along with a practical guide for how to get along and recover as a family, we create a visualization in the beginning that speaks to the sanity and health of all involved and that invites the system into greater awareness.
With this general framework for how to view and conduct relationships, we work to establish a relaxed and organized distance between the parents and client, including re-regulating the expressed emotions as needed. And, at a pace that is tolerable, we also move to begin sharing with the team, the dependence of the son or daughter. This latter process involves a certain amount of exploration, trial and error, and a leap of faith on the part of the parents and client, as they may not have much reason to trust us at this point.
As an example of how we combine sharing dependence and regulating distance at the same time, we will often join the family in working with agreements around spending money. In our experience, it is fairly common that parents will be providing spending money for their son or daughter. And, as is often the case, that may have been a contentious and unevenly regulated process, full of implied or expressed communication from both sides. When we enter that vector of relationship with them, all of a sudden we become curious witnesses to what has been going on. Everyone now gets a chance to take a fresh look and to try an informed but fresh start. Knowing that our power at this point in the relationship system is quite limited, and that the development of trust is a key goal, instead of us taking on the responsibility of setting the limits around what is an acceptable amount for spending money and how it should be given, we help the parents to develop a clear agreement with the son or daughter. We then ally with the client to organize and use her money responsibly, and to work with the feelings she has around being in such a position with her parents. We also ally with the parents in order to help them maintain the agreements and boundaries from their side. In this way, we organize and empower the strong relationships that are already there and take a supportive position with each party. As often happens, the client will have greater success with us helping her organize and regulate how she is using money. We can then help advocate with her to the parents for more freedom, more responsibility, and more money, as it is indicated. In this way, the client is experiencing success as a result of her alliance with us, and as a result of that success and increased freedom, trust can develop with us. On the part of the parents, they will be heartened to see the success, and also to practice being in a more clear and organized relationship with their son or daughter. For them, this creates trust in us and, in a small way, confidence begins to be felt toward the possibility of a recovery path. Also, the client and parents now have a more regulated and perhaps insulated distance between them, which can be a tremendous relief and refreshing change after what may have been their experience with this painful aspect of their relationship.
◈ Exchange with Family Members
Other than the more atmospheric ways that were discussed in Section II where a team “becomes inhabited by the client and family,” another common pattern of exchange is between the team leadership and the parents. What follows is an example of predictable parental exchange with the psychotherapist and the team supervisor, this time resulting in parent-child tension within the clinical team.
This particular team was for a woman in her early 30s who had been struggling with emancipation for at least ten years. One day in a team meeting without the client present, the psychotherapist, a woman, and I (CK) as team supervisor noticed that the basic attenders on the team were looking withdrawn and angry. When we asked what was going on, they reported that the therapist and I were talking to them like they were children who couldn’t be trusted to think and act for themselves. And they were absolutely correct—we were talking to them that way. This particular client had domineering parents, with whom the psychotherapist and I had regular contact, usually with the client present. Unfortunately, the psychotherapist and I were doing a splendid job of unconsciously embodying the mother and father.
In Section II we described a situation in which, through exchange with the client, I (CK) had been pulled toward his dependency needs. However, in my experience, it is much more common and powerful for the team supervisor to be in exchange with the parents. So many times, as I have finished a session or phone call with parents who may feel every bit as stuck in a predicament as their son or daughter, I have felt completely pierced with feelings that may include heartbreak, powerlessness, fear, utter confusion, self-blame, love, rage, hope, hopelessness, urgency, and of being alone with no allies. On one level, although powerful and disturbing, the feelings are relatively easy to identify and learn from. On a deeper level, much less easy to assess, lies the effect of experiencing this much parental suffering and how, if their son or daughter would just begin a recovery process, basically if she would just change, then the client would feel better and the parents’ pain would lessen, if not go away. The parents are hoping that the power to create this change lies within the capacity of the team, and specifically, for me to make their wishes known in such a way, that the client and team will cause this change to happen.
Within this interface between the team and the client and family, especially in the early stages of our work, so much of the team’s focus is creating an environment that feels congruent enough for the client to feel safe, understood, and attached to us. We do our best to accept her for who she is, and to tailor the new and various tasks at hand, for instance, collaborating to make a new home and establishing new ways of relating to one’s health, so that the stretching required is positively stimulating, producing feelings of success. Within all of that, she may be enjoying being invited into relationships that speak to who she knows herself to be in a very deep way—a basically good and sane person. Life may start to feel workable after all, and, if we are lucky, no one is having to push her too hard toward change that prevents her from relaxing. Parallel with this initial phase of the client’s process, we sometimes have the parents and their strong feelings around the urgent need to create change. As those of us know who are in the position to ally and exchange with the parents, we need to be vigilant around subtly and grossly exerting an imbalanced and unrealistic drive toward change that is not synchronized with the capacity and attachment work of the client.
Beyond the potentially intrusive power of the family exchange, there are other team dynamics that have the danger of conferring a disproportional amount of power onto the team supervisor. We have functional seniority, usually more experience, and typically have a more extensive knowledge base. We also have a significant organizational power differential with the rest of the team, especially with the team leaders, basic attenders, and housemates. Within that power differential lies our responsibility to assess their job performance on an ongoing basis. Even though we attempt to create a communication atmosphere in which people feel safe to take risks without being overly deferential toward their team leadership, it would be a fantasy to think that team members are not aware that their performance on the team is being assessed in an ongoing way. At the extreme end of this awareness for those being supervised is that “while I am opening up and taking risks, I may be confronting someone who has power over whether I keep my job or not, or whether I get re-hired for another team.” In reality, our ways of assessing overall job performance are not based on what can be the brittle views of only one supervisor. But the fact remains that between the team roles there is assessment going on.
As much as we are aware of these negative influences on transparent and safe communication, we are also aware that the functional intelligence of a team is directly proportional to the safety and openness of its communication. Some years ago while reading the book Outliers (Gladwell, 2008), I was struck by the study correlating airline safety statistics with cultural attitudes of deference toward their elders and leaders. In the case of airline safety, the more deference crew members showed to the pilot, the less honest and accurate information became available for critical decision making (Gladwell, 2008). That is exactly the case within a Windhorse team: if the junior members of the team do not feel invited to speak openly, and if the leaders are not cultivating a safe communication atmosphere, then an enormous amount of intelligence and experience will not be part of the collective known. And, in that setting, the team is flying much more blind than it should be, thus creating a disproportionate level of power skewed toward those in leadership seats, especially the team supervisor. In that scenario, decisions will be made based more on his or her “dream” of the situation, which frequently includes a healthy dose of exchange with the parents.
Aside from the above-stated vulnerability of team leadership to be imbalanced toward the parent’s point of view, there are other significant reasons it is more difficult to resist the presence of family influence. One of the most potent is that they are usually paying for the care. Though a bit extreme, an old psychoanalytic truism, “Whoever is paying the bill is the real client,” speaks to the always-present power of who controls the finances in the treatment process. Beyond that, parents frequently have clear, understandable logic as to why they want change. It is also likely that we as a team have been struggling with the client around some of the same issues that the family has struggled with for a long time. But family influence and exchange that skews the team toward a therapeutically aggressive cure; unrealistic, rapid change and unfamiliar, strict boundaries for the client, can be very dangerous. If a family, client included, has been functioning for a long time with a certain set of values and (perhaps) lack of boundaries, however difficult and problematic these patterns may be, these are the known and depended-upon rules of the system. When the clinical team and the family unilaterally change the rules in a way that is not in keeping with balanced, relational recovery pacing, it can erode the client’s trust in the clinical portion of the team. To the degree that the clinicians are seen as “having gone over to the parent’s side,” it can effectively destroy the client’s therapeutic alliance. In the extreme, such changes can be experienced as a devastating mass betrayal and abandonment by the clinicians. And, from the family, it may be seen as a communication that she is no longer wanted, loved, or acceptable. Such a rapid and unilateral change can spike the risk of suicide, as the client may choose not to play by the new rules, within the new sense of relationships, perhaps not even imagining how it is possible to do so. Suicide in this dynamic, either the act, the ideation, or in the urge toward a self-induced regression, becomes a lonely and outraged statement of the client’s aggression toward the family, the clinicians, and herself.
◈ Family Meetings
In order to avoid becoming trapped by the kinds of errors and imbalances described above, we practice having a regular family meeting schedule that includes the client, family, psychotherapist, and team supervisor. At the heart of these family meetings is the spirit of trilogue: that each member of the family and clinical team has an equal voice in the conversation. With the same sense of how we practice relationship and communication in the culture of the clinical team, we cultivate a path for the family meeting that values respect and respectful listening from the heart. With everyone learning to find his or her genuine voice, the experience of hearing and feeling heard can have a powerful transformative effect. Old and current hurts often come up early in the process, and the possibility of forgiveness may proceed in stages. As we carefully attend to the safety of the meeting environment, working to modulate the level of expressed emotion as necessary (Micklowitz & Goldstein, 1997), each family member’s power and contribution to the system can become more recognized, for both their sane and their problematic aspects. With more truthful communication being explored, as clinicians we know that modeling generosity, in the sense of not rigidly protecting our professional and personal egos, can show how to relax one’s sense of attachment: acknowledging and owning our mistakes, modeling vulnerability, honesty, and maitri. As with the sense of humor and lightness that contemplative practice can provide in other areas of our clinical work, having confidence in the transparency of thoughts and feelings can go a long way in creating a relaxed and even playful atmosphere within the family meetings.
Each team will find their own optimal rhythm for these family meetings, but they are generally held about every week to two weeks and as needed. Punctuating this frequency are seasonal reviews that typically involve the whole team, allowing us to raise our collective awareness, providing fresh perspective and the re-establishment of common goals going forward (Fortuna, 2011). We find that by structuring the longer meeting rhythms in this way, it helps the team avoid being swamped in unconscious exchange and falling asleep in repetition.
As rugged and intense as this family work can be at times, the payoff of finding our sanity, as well as feeling released from the stuck-ness of blind and painful repetitions, inspires all involved toward courage and the path forward. Confidence begins to emerge, making exploration of unfamiliar and healthier life patterns not just possible, but a natural development that feels inviting. At this point, the family will typically be trusting the team to be assuming a more primary role with their son or daughter. The client’s confidence will tend to be expressed as finding a more correct distance from their parents, using the team and ordinary community resources to expand their social context while engaging in more responsibility for their own life.
◈ Frequently Encountered Problematic Family Dynamics
We know that it can be expecting a lot to ask a client to enter into such a relationally intensive therapeutic system. Likewise, we know it can be a lot to ask parents to enter into a Windhorse family process. In the strain of working in unfamiliar territory, perhaps having a sense of being vulnerable and feeling overexposed to each other, and possibly due to us as clinicians not being adequately skillful at times, we often see stress patterns with families that require particular attention so as to not become obstacles to progress. Below are some of these familiar dynamics.
We are not able to develop a congruent contract between the client and the parents, which is common when working with addictions. For instance, the family may want an abstinence approach to substance use, but the client is in a pre-contemplative relationship to the problematic behavior and may be more appropriate for a harm reduction approach (Denning, Little, Glickman, 2004).
We are not able to develop a congruent contract between the client and the parents, which is common when working with addictions. For instance, the family may want an abstinence approach to substance use, but the client is in a pre-contemplative relationship to the problematic behavior and may be more appropriate for a harm reduction approach (Denning, Little, Glickman, 2004).
It sometimes happens that we have difficulty arriving at an agreement that the parents have work to do. The classic family “identified patient” role fits in this territory.
Parents may become competitive and threatened by the team as to who “parents better.” An example of this happened when the mother of a young woman could not tolerate her daughter forming a more positive feeling relationship with the female psychotherapist. Eventually, in an act to save the marriage as his wife demanded loyalty to her (“Are you on their side or mine?”), the father had to end the treatment. Within a year, he brought the daughter back to us, having gone through a divorce. A variation on this is that one of the parents may like us better than the other. This can be problematic if the team becomes more aligned with one parent than the other.
We often work with highly successful business people who are not as skillful in the realm of relationship, communication, and parenting. Within such a dynamic, we may see reflexive habits of top-down management, distrust, power differential abuse, and financial manipulation of the family. A variation on this is the expression of power and control toward the team, through the financing of the treatment.
Sometimes parents can become mood-unstable themselves (or otherwise symptomatic) without acknowledging, or even knowing that this is the case. Denial of their problem and projecting the fix onto the son or daughter is one variation; wanting to assume the management of the team is another. A further variation is a parent who is in denial about his or her own mental health issues and needs and will obstruct reasonable interventions for the son or daughter.
Splitting is common between the family, client, and team. This may be a habitual way that the family has interacted or it may simply be how the client’s mind works at that time. Splitting may also arise at times when we have created too much therapeutic tension and this becomes unreasonably difficult for the client. In the latter scenario, it is common for the client to speak with the parents about how basic attenders may not be showing up for shifts, or there is no food in the house, or even that someone may have hit her; none of which is happening. We attempt to identify this possibility up front with the parents, and to encourage them to resist reflexively siding with the client if he or she is saying something that seems undermining of our competence and/or ethics. We also want the parents to share such complaints with us so we know what they are hearing as well as to make sure that the complaints are not valid.
A common dynamic, and part of why we are proactive in establishing and maintaining a strong therapeutic alliance with the parents, is that they can develop the same feelings toward the team that they have toward their son or daughter. In that scenario, the qualities of what they have experienced of the suffering and frustration of parenting get expressed toward the team. “The team costs too much; you don’t really do anything; you’re disorganized; this is going nowhere; you’re not even trying,” and, “You did it again.” When this dynamic occurs, the team ceases to be perceived as an adult partner, thus making a collaborative alliance at least difficult.
The counterpart dynamic of the last point is that, as we are developing our relationships with the client who is struggling with emancipation, we need to carefully differentiate how we relate to her and how we relate to their parents. For instance, if possible when meeting the parents and the son or daughter, I (CK) will shake hands or greet the client first as recognition that she is a respected member of the group. Although the gesture may appear insignificant, along with making sure she is included as a valued part of the conversation, it may help her to feel like she is not just tagging along to be ignored, while the “adults” have a conversation about what “They are going to do with me now.” This also relates to why we primarily limit the parent’s contact to the team supervisor, who is most likely to land the more difficult parent transference from the client. By doing that, the client knows that she has the primary relationships with nearly the whole team, including her psychotherapist, and that the parents are not constantly creating a more “adult” alliance behind her back. Knowing the parents are at a more safe distance and insulated from her team allies, it is much easier for the client to relax into developing genuine relationships and letting go of continually needing to emancipate from us. This is especially important in the early phase of the team, while we are attempting to create a healthy therapeutic dependence. To the degree that we are successful in doing what we are describing, the team will not be perceived by the client as simply being an extension of the parents.
Fortunately, these more problematic dynamics with families are well known to us and we take the approach that honest and direct communication will tend to create trust and openness. In so many of these instances just described, the family is not surprised by what we point out, and by now they may have a strong sense of revulsion at helplessly recreating such painful experiences. Through openly and gently identifying some of the more sensitive and dysfunctional repetitions, it gives us all the chance to understand the intelligence and functionality of the behaviors. From there we can then work to transmute the confusion into awareness and change.
As the life of a team is typically between one to two years in length (some much longer), the client, family, and staff will have a rich path of opportunities not only to talk about how to create healthier relationship and life patterns, but to collaboratively practice them as well. Functionally, a good part of what happens over the life of the team is that the parents and client become well practiced in living and exchanging within this synchronized whole-person environment. Thus, what was once a more compensatory and dependent arrangement for them, an external ego, has now become internalized. Optimally, out of this experience comes an allegiance to sanity, and disciplines that sustain and organize life in accordance with one’s basic health. The family, parents and client, will now have a resilient way of being in life and relationship, with practiced and internalized skills for the path forward in ordinary life.
Conclusion
We know groups to be a potent therapeutic form. In the Windhorse approach we create a specific and unusual kind of group process: a highly cohesive therapeutic environment in which the client and family are integrated and often outnumbered by Windhorse trained clinicians. Under the correct conditions, this can provide an energetic critical mass, facilitating healthy change for people who may be experiencing multiple, difficult, and synergistic problems. When the client and family function and exchange as part of this environment over the appropriate period of time, their intrinsic health and urges toward sanity tend to naturally arise and stabilize. And when done properly, this process also produces significant benefit and growth for the clinicians as well.
Although this discussion has focused on the process of a Windhorse team, we know that much of what is described here relates to other therapeutic settings. Inpatient and residential treatment, as well as many forms of outpatient milieus, will be situations where such exchange and group dynamics are occurring. We hope that our hard-won knowledge may be of benefit to clinicians working in these other environments.
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