This was written last year and first shared on “The PDA Practice Corner, on Facebook”. These are therapeutic insights derived from creating rapport and therapy space with over 200 PDA adult clients over the past 3 years. These insights have a foundation in psychodynamic theory, general observations and personal insight into the needs of PDA adults. Thanks for reading.

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An active engaging therapy is a resisted therapy. To the therapist not prepared for PDA friendly communication this feels as if they are being pushed out of the inner life of their client. This is not the case. As your client masters their moments in regulation with you, you will feel urgency and intensity decrease. You will feel them slow down and their fight or flight response deactivate. The engagement will happen by exploring the feelings in the resistance if you are willing to learn PDA friendly communication.

Like any good therapist at the point of resistance you know that you can verbalize what you think is in the resistance and ask your client if you got it right.

If you then see tension reduce you know you did! This will allow you the chance to offer an intervention. You can do this by formulating big picture questions found from considering what emotional material might be stuck at the point of resistance because you are looking to engage safely.

Such questions provide a context from which you and your client can explore meaning and purpose which is self-directed and fosters autonomy. You’ve then facilitated a safe accommodated engagement. Your client is free to explore their own feelings.

Questions serve as a method of organizing detail into a context which promotes the recognition of feelings. Awareness and recognition of feeling is promoted by joint attention in regulation sitting at the intersection of THOUGHTS and FEELINGS. The PDA person is often trapped in their own thinking. But in safe interaction they can be engaged and open for feedback and often shift their own thinking because they can safely attend to it with you.

When listening to their client answer big picture meaning making questions the therapist can show the PDA person how therapy works by doing what any good therapist does. Reflect back what they hear, validate what feelings might be there, and ask even more expansive questions which serve to maintain the calm of the nervous system while your client considers input and context.

If communication feels expansive and easy the therapist will know that they have hit a good question. Good questions are the key to GOOD PDA THERAPY. You and your client are navigating and then suspending demand avoidance while processing an experience together in clear coregulation and nervous system safety. The PDA person will consider a good question and may linger with it for some time expanding their thinking and finding their feelings there.

Resistance to you, your feedback, looking at feelings…. anything, is actually the place for a “good question”.

FIRST SESSION, Case Example

The therapist begins the initial session with a question, “How do you intend for therapy to be meaningful for you?”. Their new client answers saying, “I am here because I want it to be. But, so many therapists in the past didn’t seem to get me. I stayed because I thought it was me and wanted to give therapy a chance”.

The therapist then asks, looking for meaning, “You are trying again. What does it mean to you that you feel understood”? TENSION releases and the person with PDA becomes quiet and stays quiet. Then, the client responds saying, “hmmm, good question”. They remain calm but offer no response.

The therapist expands here looking for context “I wonder if it is a feeling, you’ve had outside of therapy too, of not being understood”? This elicits shaking of the client’s head but still no words.

Tension releases however and the client appears very calm. In this moment, the client releases sad affect to which the therapist offers feedback and further questions to help the client find co-regulation in being understood. “Finding words to explain yourself is hard and you can use this space over time to find your own words to describe your feelings. I know of others in my practice for whom this has happened. And it’s been a relief to be seen and understood”. “Do you think this could be you too at some point?”. The client answers with “I don’t know. I’ve never felt that way with anyone except for my brother.”

To this, the therapist answers with “Is your brother very important to you”?

The PDA client answers by saying, “Maybe this is why I want to come back to therapy. I miss my brother. Even if I’ve never hit it off with a therapist, I want to feel understood again. Just being here I am thinking about my brother again”. The client releases even more sad affect right here and stops talking.

The therapist stays here, realizing that they opened up something that is connected to resistance in the current therapy that may not yet feel safe. The therapist is looking for context and big picture questions for more safely regulated engagement. The client however lost words to strong affective response and it is clear that the client is disengaging with the therapist at that moment. They are instead engaging with their own internal dialogue almost at the point of overwhelm. They look down and away and can’t reengage. The therapist stops speaking for a time and sits with the emotion.

The therapist uses the PDA Emotional Filter (demand avoidance as defense mechanism to protect against overwhelm) to reestablish the client’s boundary and restore safety. The therapist says at this moment, “You’re just meeting me, and I wouldn’t want you to have to decide or be sure if I can be safe”. “Share things with me when you are ready, and I respect that”.

The therapist stops talking and remains calm. The therapist does not speak. The client regulates with the therapist and the sad affect dissipates. The client then shares more context with the therapist (notice that they needed a boundary and to express emotion before being able to speak) “You know, I almost never talk about my brother”. I’m surprised I did. I think of him every day recently. His name is Luke. I also never cry. That surprised me”.

The therapist answers with a “purpose and meaning question”: “what does it mean to you that you are thinking about him every day and thinking about him now”? The PDA person shared that “he would understand what I’m going through and I can’t call him”.
The therapist answers with a “big picture” meaning making question: “Are you looking for me to understand something hard or painful for you?” The client says: “Yes, I guess I am. I can’t always turn to my brother. He’s a father now with two young kids. But I’ve never been totally understood. Sometimes my friends can understand what I need but I’ve never had a therapist who can do this.”

The therapist experiences the PDA client enter resistance and disengagement again with that statement to which she says: “You won’t know right away if I can understand you. Trust and understanding takes time and I’m willing to take that time.”
Here the therapist does something to indicate that she has been listening by saying, “please let me know at any time if you feel I am misunderstanding you. You realize that your brother’s life has changed, and you want to respect him while also figuring out how to care for yourself”. “Is that accurate?” The client stops and considers. “Yes, I think so”.

The therapist then ends the session with another meaning making question saying, “if I am a therapist who can understand you, what will it feel like to be you 3 months from now?” The client leaves the session considering this and saying that they want to feel less overwhelmed and learn how to care for their emotional life. This was a complete session.

In this time the client engaged and disengaged multiple times. This “resistance” facilitated engagement through the clear client centered focus of the therapist who asked questions about the POINT of their resistance. Why, what’s in it, how is it important, what does it mean to you. THESE KEY QUESTIONS will be the way therapy moves forward. You do not move forward until emotional safety is reached.

Notice as well that your client didn’t share what it is they came to discuss!

You may have many sessions where your client resists speaking of what matters. Directing this process will create anxiety and you may then see an attempt to shut down communication or “push back” against the therapist’s engagement by contradicting what was just said or even restating it in a slightly different way. You did not “get it wrong”, you were “too direct” or two quick to move through resistance as your client was not with you. Welcome resistance in PDA therapy spaces. You will see a lot of it! A PDA affirming therapist is very comfortable exploring it.

All client work has been generalized with no identifying information shared. This is not to be considered professional consultation. Look for more detailed writings on the therapy space. Reach out with any questions at EliseJacobsonLICSW@gmail.com.