Comment: Importance of Physical Environment in Therapy

I read a post called The importance of the physical environment to client comfort by Behind the Couch. She reflects on the oft-stated “requirement” that physical comfort and safety are a first priority in therapy. Considering therapy within the realm of Maslow’s Hierarchy of Needs, we strive to make our homes safe and comfortable. “So,” she asks, “why should this be any different in the therapist’s room?”

Her post and the many great responses made me consider the unconscious discomfort I felt as well – one unusual item in particular.

Part I of trauma therapy deals with safely – emotional and physical (Herman). I never got past that phase before leaving my therapist. It took me a while to realize that the therapy room itself was part of the problem (but not the primary reason I left). I wrote about therapy, safety and trust a while back.

Behind the Couch explores why some therapists could discount the physical environment when they strive to be so finely attuned to the client’s emotional needs. The disparity is huge and this disconnect between client and therapist is not the client’s responsibility to resolve. Of course, if the client is able to recognize and verbalize the source of discomfort, she should raise the issue. But a therapist should be in tuned to discomfort and explore the real source(s) more fully.

Cheap plastic chairs. Uncomfortable flimsy chairs. Room switches every session. Noise outside. Some of my favorite physical peeves are from folks who commented on the post as I did, including Tarf’s comment about four lost sessions over a foot stool, calling it “the single most bullshit waste of time of my therapy to date.”

While the post and comments made me laugh and bang my head on the table at the same time, they also made me think about the physical environment I took therapy in.

I had four main issues –

1) The room was not soundproof. I could hear the client before me. I told her, and shortly after she installed one of those white noise machines. It worked for normal conversation levels and that improved my comfort level.

2) Her chair was higher than mine. She had a straight backed desk chair; I sat on a squishy couch. In the beginning, when I needed someone to hear and believe the stories I had to tell, the positioning did give passive comfort. Maybe that whole maternal thing. But as I grew stronger emotionally, I realized I felt below her emotionally. Smaller. That she was somehow more powerful or “right”.

I found I needed to be an equal in my own therapy – in my own understanding of myself. This issue contributed the final explosion that accompanied my leaving therapy – which of us was in “control,” and that apparently with her, we both could not share that responsibility.

3) The room was kid-focused. My therapist does a lot of therapy with kids. The room was small and a good third was dedicated to making kids feel comfortable – small brightly colored chairs and tables, shelves of children’s books and toys. A jar of candies. All placed about 2 feet from me.

As an adult, I felt like I was intruding in a way. That I had not “outgrown” my need for therapy. That I was STILL broken as an adult; something wrong with me for which I STILL needed therapy. I cannot put words to describe that feeling of discomfiture.

And finally,

4) Capital Number Four – my holiday present. As if numbers could be capitalized. But for this item, I would.

Early in my therapy, my therapist focused on PTSD symptoms, and then we got to the more severe dissociation problems. Since I felt so “crazy” about the stuff in my head, I was hesitant to be so open at first. A few months in, she assured me that I did not have Dissociative Identity Disorder. To which I blurted out, “Then why do they have names?”

That was, most likely, a turning point in my therapy. She did not deny it after a few more sessions and it was confirmed by a specialist, but my therapy began to veer in directions where she had little expertise. I was her first client with DID. To her credit, in the beginning, she was willing to hear my between-session research and explorations. We extrapolated her expertise in PTSD and severe dissociation.

After the first 4 months of therapy, I was finally relieved I wasn’t “crazy.” Excited – so happy to know what was really wrong! To show my appreciation, I bought second copies of two books on DID that I most identified with. Books that described ME. (Stranger in the Mirror and Multiple Personality from the Inside Out.) Books I thought would be useful for us to discuss and explore. I gave her these two books as a gift for the holidays. Giving pieces of myself.

Recognizing and honoring all inside me.

She thanked me genuinely for the books, and then she placed them horizontally on top of a row of books on her shelf. Not vertically side-by-side with the rest of her books. From that day until I left therapy 6 months later, she never touched them. Emotionally relegated. Crookedly placed and somewhat offset from one another, they never left that position. Static performance art, placed just so, in a way I recognized each time I entered the room.

Initially, I thought Capital Number Four was a stretch beyond the topic Behind the Couch introduced. But then I decided it really WAS a physical thing that COULD have given me comfort. Even just a confirmation that I BELONGED in that room, if I had only seen those books move a smidge.

I had offered those books as a way that she could better understand ME. But she never showed the interest to crack either spine.

See also:
List of all posts
Therapist consultation for dissociative identity disorder
The ability to trust with DID in therapy and in real life
Changing therapists – what to consider
Guest Book and Introductions

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11 Comments»

  behindthecouch wrote @

Hey Em,

Thanks for posting back and for the comments. The book thing is appalling. It made me really angry just to read about it – insulting and disrespectful. I want to know what the hell she thought she was doing!

I haven’t experienced anything similar with Goodtherapist but I think we have enough respect that if I asked/suggested she read something she would damn well do it or tell me why not.

Sometimes I think therapists are not as bright as they should be.

So sad.

BTC

  emilylonelygirl wrote @

Hi BTC

Yeah, you know how you bottle little things up because you think you might be over reacting, and you may even be TOLD that you are over reacting about something? But it is still stuck in your craw (“throat” for my international friends)?

The book thing didn’t really get mulled over until I/we read your post. It was me who it bothered the most in here. Then I realized my hurt/disappointment had been justified.

So, thanks also back to you for helping me set another little thing straight inside myself. The position of a couple books – so insignificant and yet so telling.

Emily

  Secret Shadows wrote @

Oh…..that is so sad about those two books. Heartbreaking, really. I am so sorry you had that experience. I like those two books as well. The Stranger in the Mirror is absolutely excellent!!! And MPD from the Inside Out is one of the first books we ever read on the topic and we identified with it so much. That was back in the 90’s, and though it is dated, expression of the internal reality of DID is never dated.

  Jackie wrote @

How very sad for all of you that your gift was disregarded in that manner. When I read this, thought crept to mind “grab the books and walk” yet another sobbed at being looked over yet again and felt your pain.

J

  emilylonelygirl wrote @

Jackie

That is exactly what happened in a sense. Part of me despaired of leaving her…please don’t make us leave, Cami! Other part said: fck this, we are done here. Another: leave the books on the shelf as a reminder (when she ever notices them again) of what she lost.

Em conceded, and knows it was the right thing, but it hurt. It always will a little, because it was a betrayal. But at least it was not our fault that we were betrayed – for the most part, the pain is settled resolution.

And that recognition and acceptance was, we realize, what made that therapy worthwhile.

(In the post and in this comment, I left in the conflicting feelings about the therapy and that book, because there is and has been disagreement at a gut level about what it signified. “She lost.” “I wish she would have seen.” “Idiot.” “What is wrong with her?” “bitch”)

While I have trouble reconciling the opinions into one cohesive voice at times like these, I think it is okay, because we all agree on the outcome. It signifies growth.

(My god, we sound like a philosopher!)

  behindthecouch wrote @

Hey Em,

What a complex world it is 🙂

I think too often we end up thinking that we can “punish” the therapist by leaving but all they really lose is the income. I don’t think they honestly see quitting therapy as anything more than “acting out” though I’d love to be proved wrong on this.

I think the therapists that really care enough to find out what the problem is, work through the resistance and keep you in therapy (if appropriate) are the ones that clients don’t leave. I hear nothing but sad tales about premature terminations.

Quitting therapy in your case, as we’ve discussed before was completely the right thing. The therapist sounded totally unable to connect with you despite your efforts – if anything it should be the other way round – it’s her responsibility to find a connection to you.

Grrr this makes me so mad…

But I agree with Jackie it would have been good to go grab the books on the way out – just to make sure your message was received.

Maybe thats just me being vindictive on your behalf.

All of you have my support 100% for what it’s worth.

BTC

  emilylonelygirl wrote @

BTC

Yeah, I hear ya. Vindictive – I think it might be taken that way. I KNOW my therapist feels this is my fault, if “fault” is the right word. I believe she thinks I was refusing to acknowledge what she thought was wrong with me, and what I was denying.

I could get mad all over, but the bottom line is that 1) I recognize what we BOTH did wrong, and 2) I have moved on.

Thanks for your support!

Emily

  David wrote @

I was really struck by your very insightful descriptions of why the physical environment of the office was problematic. Although I’ve had some crappy therapists, you’ve made me realize that I was fortunate in that all of them were very sensitive to appropriate physical space, and created a setting conducive to doing work. I have particularly appreciated the fact that all of them have had boxes of tissues very discreetly placed, but easy to reach — I have yet to need them, but it’s nice that they’re there but not blatantly there, like the therapist expects every client to break down sobbing immediately.

You’ve also made me realize, yet again, what an amazing therapist I have. Your story about the books just … well. No wonder you were hurt. It hurt me to read about it. I remember one of the first things Debbie told me was that she has consulting relationships with several researchers and experts with DID and trauma disorders, and that if we got really badly stuck, she would always assume responsibility for that, and figure that she was missing some piece of information or protocol relating specifically to how DID manifests with me, and that she would consult with her colleagues to find a solution, because no single person can possibly know or experience everything. As someone who had frequently been blamed by therapists for staying deliberately stuck or not wanting to make progress when actually I was trying as hard as I possibly could, this was enormously reassuring.

Your therapist should have read those books. Better yet, she should have suggested another therapist, or at least collaborated with someone who knew what the heck was going on.

  emilylonelygirl wrote @

David

Auaughghgh! Yes, i forgot the TISSUES!

She had them on the back of her desk which was at right angles to where I sat on the couch. I could see them, but they were about 5 feet away and awkward to reach (I would have to get into her personal space and her desk space, which feels like it is “her” turf.)

If I started to tear up, she would often give me a tissue directly – not bring the box to me.

Strange. Looking back, it is almost like she was metering out tissues one at at time!

I am not being fair…the tissues should have been closer, but I have to be careful not to read too much into it.

Thanks
Em

  Jackie wrote @

Tissues! Those darn multi flowered or colored boxes of tissues and the multi people within me have this on-going battle with each other. Sometimes T interrupts the civil riot going on in front of him and I want to scream at him to “Shut up, can’t you see we’re in battle here”. lol.
In all seriousness though, do they really think that we have to break down to make progress? It’s the little things that work for us.
And I still think you should have grabbed the books and left….perhaps grabbing the dam tissue box too that is in your T’s space!

J

  emilylonelygirl wrote @

Laughing!!!!!

I am going back for the books and the box of tissues!!!!

Break free of the therapy room intimidation!!!!

Cami/Em


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