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