How to Work with Clients that are Stuck in Therapy

Brad Kammer

19 Posts Published


November 18, 2018


As clinical consultants over many years, we have found that therapists usually have on their caseloads a few clients that are especially frustrating because of their lack of progress in therapy, in addition to clients who make good progress, only to regress back to old, stuck patterns of self-sabotage, hopelessness and despair.  These are usually the clients that therapists bring to consultation.  The question we get asked repeatedly – how can I most effectively help this client?

To answer this, let’s revisit The ACEs Study (Adverse Childhood Experiences).  The ACEs Study has a fascinating origin.  Originally, it was designed as a weight-loss program until the head of the program, Dr. Vincent Felitti, observed that despite making successful gains toward their weight-loss goals, nearly 50% of the participants were dropping out.  This did not make sense to Dr. Felitti at the time: why participants would leave the program as they were losing weight and coming close to meeting their weight-loss goals.  He created a questionnaire to understand this phenomenon and discovered that a majority of those that dropped-out had experienced childhood trauma.  Thus began the monumental research project we now refer to as the ACEs Study.

One fascinating aspect here is the underlying mechanism of self-sabotage.  One would think that the closer a participant got to their goals the more motivated they would be to complete their program.  But whether it’s weight loss, or a student dropping out their senior year of college just a few credits shy of graduating, or someone who has been sober and returns to their substance use, we see so many examples of people getting closer to health, wellness and success turn to behaviors that are self-sabotaging and self-destructive.

Working in the field of unresolved developmental trauma, this does not surprise us.  We have come to recognize the “survival” function of shame and self-hatred.  As young children, everything revolves around staying connected to our caregivers – what we refer to in our field as attachment – this is essential for our basic survival and well-being.  When there has been failure, whether from our caregivers or from the environment, our basic survival is threatened.  Children are unable to experience themselves as being good people in a bad situation.  Therefore, unconsciously, psychobiological mechanisms turn on to assure our basic survival.  A main survival strategy is what we might refer to as shame and self-hatred; that children experience themselves as bad as a way to protect themselves from their failures of their caregivers and/or environment.

So what does this look like clinically?  When the therapeutic process gets thwarted, when clients use strategies like avoidance, distraction, self-criticism, and acting-out, when clients begin to get better and then repeatedly have set-backs or sabotage it in a number of ways, we can begin to recognize that shame and self-hatred are acting as glue keeping them stuck from moving forward.  Going back to the original weight-loss program, something is threatening about moving forward in life toward greater health and well-being.  That something is the way we learned to protect our early caregivers and environment through foreclosing fundamental aspects of ourselves, even if those fundamental aspects are positive like growth, healing and aliveness.

These early failures are what Oprah Winfrey recently referred to as the “hole in the soul”.  If we don’t recognize the underlying shame-based wounds that have led to dysfunctional strategies, behaviors and symptoms, we will miss out on how to support our clients to continually move forward.

The NeuroAffective Relational Model (NARM) is a therapeutic approach designed to work with the unresolved wounds and patterns leftover from attachment, relational and developmental trauma.

In NARM one of the clinical skills we use is what we refer to as “Tracking Connection-Disconnection”, which helps support clients in understanding and working with these unconscious binds.  This integrated “top-down” (psychodynamic) and “bottom-up” (somatic) approach works with the psychobiological patterns of shame and self-hatred that have been laid down from early trauma.  In NARM, we recognize it is not enough to just identify and understand these patterns of self-sabotage and self-destruction, we also have to shift the physiological and emotional patterns that are fueling the self-limiting beliefs and behaviors.  Then, our clients have a possibility of moving forward unencumbered by these unconscious survival strategies that have come to dominate their lives.  Freedom from childhood trauma is possible.

If you have clients that are struggling from unresolved early trauma, and would like more information on how to provide more effective therapeutic support for your clients, we invite you to learn more about the NeuroAffective Relational Model in our online or live training formats.  For more information and training in NARM, please visit our website at:

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