from Clinical/Therapeutic Issues
Introducing The First Stage of Therapy with Women with Same-Sex Attraction: Securing the Foundation
Part 2 of a two-part series
By Janelle M. Hallman, MA, LPC
As a review, the first stage of therapy with women with same-sex attraction can be broken down into three separate therapeutic tasks:
Creating Safety – the Heart of the Helping Environment
Fundamental Therapeutic Processes:
Acceptance and Attunement
Client’s Task: Rest
Building Trust – the Heart of the Helper
Fundamental Therapeutic Processes:
Caring and Commitment
Client’s Task: Receive
Establishing and Maintaining a Secure
Attachment – the Heart of the Relationship
Fundamental Therapeutic Processes:
Empathy and the Here-and-Now
Client’s Task: “Become”
Part 1 in this series detailed the process of therapeutic acceptance and how it can further a woman’s sense of safety in a therapeutic or helping setting. Following is a look at the process of attunement and its significance in creating a safe holding environment for the women with whom we work.
Safety in Attunement
One client told me:
You were silent a lot. I knew you were listening. Your silence said, “Keep talking, I’m engaged with you.” You always looked at me, even when I had to say disgusting and shameful things. You even leaned forward. Those kinds of things comforted me. I knew you were with me, listening and you were not grossed out. — Ellen
Attunement is the nonverbal communication such as eye contact, facial expression, voice modulation, gestures, and timing and touch,  common to the relationship between a young child and mother, “in which both are sharing affect and focused attention on each other in a way such that the child’s enjoyable experiences are amplified and his/her stressful experiences are reduced and contained”  (emphasis mine).
I recently watched a video illustrating the power of parental attunement. A mom of a six-month-old baby was first instructed to remain attuned and engaged with her baby by entering into the baby’s emotional states. When baby laughed, mom laughed, affirming the baby’s joy and pleasure. If baby became agitated, mom showed her care through her facial expression and reassuring touch. When baby practiced cooing out words and gurgles, mom reflected her pride and encouragement through her eyes and mirroring gurgles. The baby was engaged and energized.
But then mom was instructed to break attunement by retaining a blank expression or turning her face away from her baby. The baby initially continued in their playful joyfulness. But when mom only offered a deadpan response, the baby became noticeably agitated. But mom was not there to reassure him. Mom looked away. The baby became more and more overwhelmed with his distress and growing insecurity. He tried and tried to engage mom by flailing his limbs and releasing audible whimpers, but to no avail. The baby eventually slumped in his little infant seat, lowered his eyes and attempted to find comfort by sucking on one of his small hands. His inner self had literally shut down.
Parental attunement is considered by attachment specialists to be one of the most influential processes in developing a core self within a child and maintaining a secure attachment with the child even into the child’s adulthood.  Without it, a child lives within relational isolation. The formation of their basic sense of self will be severely altered if not altogether arrested.
Unfortunately, many women as young children, like this baby, lacked consistent moments of attunement.  They missed the significant ongoing experience of being the object of another’s undivided, engaged, and regulating attention. They were, therefore, deprived of the environment in which to grow and develop their own feeling states and foundational core. Even now, they can be easily flooded with the shame of emptiness and fear of abandonment when they perceive they are being met with deaf ears or a disengaged heart. Therapeutic attunement is a powerfully healing and curative technique for these women. It can literally reestablish the environment in which a woman can continue her inner formation. A woman describes this experience:
I was shocked the first time I visited Beverly, my new counselor. She was so caring and compassionate. While she listened to me, tears came to her eyes. I knew she was right there with me. I knew I had someone who cared. This was huge for me! I cannot tell you the healing I experienced. I so needed somebody to just listen and care for me. It was a safe haven. — Joyce
In order for me to offer my clients full attunement or emotional communication, I have to open myself and allow my “state of mind” to be influenced by them. My goal is to align my inner state so I can experience, as close as possible, what my client is experiencing within her subjective or inner world in any given moment.  I then communicate my attunement through my eye contact or gestures.
If my client lowers her chin as she speaks, I lower mine and form a slight frown, as I attune to her dejected affect. As she glances out the window, I follow her glance, shifting my position as I attune to her discomfort and anxiety; I then recenter my gaze on her face. When she smiles, I take a deep breath and slowly release it as I feel her relief and joy. When she frowns, I tilt my head, showing a look of consternation as I remain with her in her sadness. As a woman timidly attempts to articulate her thoughts, I soften my speech. When she comes at me with force and anger, I place my feet on the floor, rise up in my chair and lean forward with strength and centeredness – and a slight smile. I am with her and I can handle her.
Attunement sends the nonverbal message that she is being understood in the deepest sense and is therefore not alone. You and she are in harmony, experiencing something together. And since you “with her,” she feels safe.
I remember you looking at me after I had shared. You were hugging me with your eyes. I had goose bumps – the hug felt real. Light and warmth were coming from your eyes, totally engulfing me. It was truly incredible. I felt something touch me down to the depths of my soul. — Wendy
The experience of attunement affords a woman the structure and support she needs to begin to connect with, regulate, and understand her own emotions, reactions, and behaviors. As she reflects on these experiences within herself, she may be able to acknowledge and therefore integrate previously ignored, denied or neglected aspects of her self.  “The job of psychotherapy then is not to deemphasize, defuse, or discharge these moments of oneness, but to encourage, heighten, and embrace them instead. Only then will we be helping patients in their recovery from their detached, alienated core.”  As another writer explains:
The affective experience of igniting an empathic connection between two separate beings is the magic of love, the holiness of spirituality, and the miracle of humanity. That two beings, separated by a lifetime of unique experiences, can “feel themselves into the other” is truly extraordinary. 
Containing and Regulating
Attunement is especially important in helping a woman to regulate and manage her anxiety. Just about every woman with whom I have worked, struggles with some form of anxiety. It may be familiar to her, something she has lived with for years, or it may be circumstantial, arising out of the newness or nature of the therapeutic work. It may serve as a “blanket” emotion used to cover other powerful emotions she has never felt safe or strong enough to face. Regardless of its source, I have learned it is extremely important that I handle her anxiety with concern and respect. As I deal with it in this way, she learns by example how to welcome, regulate, and process not only her anxiety, but also all of her feelings.
In the beginning stages of our work, I carefully attune to my clients, noticing any indication of agitation or fear. She may halter in speech or twist on a Kleenex. She may tap a foot or continuously shift positions. My goal is to intervene long before she begins to verbalize her discomfort or inability to proceed. I gently stop our conversation, saying,
“Alaina, you just told me a lot about your family. I know it was hard for you so I really appreciate the effort you are making. But I’d like us to take a break.” Pausing and then speaking slowly, “Why don’t you relax back into the couch and take a deep breath in… and then slowly let it out.” (Notice, I do not tell her she is anxious.) “Let all of the tension you are holding just flow out of you as you slowly exhale.” (I coach her and do the exercise with her, exaggerating my intake and release of air. She can basically mimic me. We both relax.)
“Okay,” I say, smiling and leaning forward. “You are doing great work. We will continue your story next week. For now though, I would like to hear what it was like for you to share all of that information with me.”
We then reflect on her experience of sharing. This helps her to integrate or “take in” the experience as a warm positive moment of connection and acceptance (in contrast to all of her disappointing moments of rejection or neglect).
Go Where She Goes
Many women with same-sex attraction have spent a lifetime figuring out what other people want or like so they can please them. Pleasing others is often one of the only ways a woman knows how to gain a sense of connection, acceptance, and value. I learned fairly early on, thanks to the honesty of my clients, that many of my clients tried to “read” me to determine what “I wanted or expected” so they could perform as good clients. I knew this could become extremely destructive to my client’s therapeutic process if I, for example, unconsciously needed her to cooperate with my treatment agenda for my ease or sense of security. I would be simply reinforcing a woman’s energy to please. Safety would be breached if she were to be used towards my end.
I have, therefore, made it an ongoing habit to continually check my hidden goals, agendas, or expectations I might have with respect to my clients. I also want to actively invite her to step out of this historic role of pleasing others by taking the initiative to discover what she wants or likes. Irving Yalom emphasizes “Above all, the therapist must be prepared to go wherever the patient goes, do all that is necessary to continue building trust and safety in the relationship”  (emphasis mine). Therapy, in this initial stage, must be thoroughly client centered.
I contemplated this concept at a recent baby shower. Many mothers and young children were present but one little girl caught my attention. Her eyes were as round as her face and her cheeks were even redder than her hair. She was about one and a half years old. She was dressed in a pink frilly dress with white lace anklets and paten leather shoes. She seemed oblivious to the “frill” as she walked, jumped and crawled in between the guests, up and down off of chairs and out into the garden. She delighted in exploring her world.
I wondered how her mom was handling being mom to a not so frilly active and adventurous little girl. At one point mom made a comment her daughter loved to play with cars and trucks. “Yep,” that didn’t surprise me. The little girl seemed developmentally healthy though, as she regularly ran back to mom through out her explorations. But there was one dynamic I couldn’t help noticing.
As she returned to mom, the little girl tried to speak. In response to her unintelligible sharing, the mom scooped her child up and plopped her on her lap. The youngster immediately tensed into a stiff statue until mom put her down. She then whined out a few more words (maybe sentences) and finally returned to her wide-open spaces.
I was glad to see the mother was attentive to her little girl’s need for affection and comfort. However, I couldn’t help thinking mom was nevertheless “missing” her daughter, similar to how an arrow misses the round bulls eye. The archer no doubt wanted to hit the target, but was lacking something in terms of technique or aim. I think this little girl wanted her mother to come and explore the world with her. I suspect she would have been delighted if mom had left her chair and walked the garden or followed her into the house. I think the little girl wanted her mom as an exploring companion. Perhaps she would have felt safer, not to mention known and loved.
We have the same opportunity to go where our clients go. We can stick to our “cushy chair” or preferred styles of therapy, or metaphorically get up and follow our client’s lead. Similar to our little redheaded friend above, the woman with same-sex attraction needs to know she is valuable and important enough to be followed. She longs to be pursued and known. She longs for connection that doesn’t require her to do all the work.
“I worked so hard to keep you engaged. I did my homework. I intensely pursued my issues. I wanted to please you. And I figured if I ever stopped working so hard you would leave or terminate. What I realize now is that you were always engaged and it wasn’t dependent on my performance or intensity. You always reflected back to me commitment and stability. When I finally realized you were committed to me, not just my process or work, I knew I was experiencing something completely new. It was absolutely pivotal! I can now say I shifted from a state of performance and intensity to warm and settled intimacy, for the first time in my life.” — A woman speaking to her counselor
In the beginning stages of therapy, if a woman would rather tell me about an incident at work than continue talking about her childhood story, I will wholeheartedly engage as I follow her lead. I stay with her (fully attuned) while she shares yet another aspect of whom she is. I will not force her to reenter her past until she is ready. Truth be known, she probably doesn’t care that much about addressing “past” issues, at least at this point in time. She is much more concerned about my ongoing presence and ability to stay with her, wherever she goes.
She’s Doing The Best She Can
To add to my client’s sense of safety, I also allow a woman to experience and express her emotions and visceral feelings in the best way she knows how. Feelings of any sort are often difficult for most of these women to identify, experience, let alone articulate with another person. I have learned to be patient and calm as a woman sorts through her inner turmoil and displays certain behaviors related to her discomfort.
Danielle, a 45-year-old woman who had embraced a lesbian identity for over 11 years, told me about an experience with a previous therapist. In their second or third session, Danielle felt such agitation she got up out of her chair and began to pace as she and her therapist continued to talk.  Danielle’s therapist eventually asked her to sit down because Danielle’s walking was distracting her. This therapist was evidently uncomfortable with staying present to Danielle’s agitation as manifested by her physical movement. As you might guess, Danielle never returned.
This therapist missed an incredible opportunity to enter into Danielle’s “disordered” world and simply be with her. A group of therapists in the 70s discovered this very essential need:
A human being cannot suddenly give up all the images, roles and symbols of his existence, for he would have to face the unknown with extreme fear. He needs someone who can take him into and through his disorderedness to the reality of his impulses, thoughts, and expressions. He needs to make contact with another human being (emphasis mine). 
Hughes claims if a child’s or client’s disordered behaviors habitually annoy parents and therapists, those behaviors will resist change. However, “if we truly accept these behaviors, they are much more likely to change.”  Following is an example of how I interacted with one of my clients after they had started pacing in my office:
“Are you feeling better, now that you have walked a little?” I asked in a warm and caring tone.
“Yes, yes I am.”
“Do you know what you were feeling when you first decided to get up and start walking?”
“I don’t really know.”
“Do you remember what we were talking about?”
“Well I think I do. You briefly mentioned your mom died when you were four years old. It must be very hard for you to talk about.” I leaned forward and maintained eye contact with her as she continued to pace.
“I didn’t think it was hard to talk about.”
“What are you feeling right now?”
“I guess okay, but a bit bothered you’re asking me all these questions.”
Catching her increasing anxiety surrounding my probing questions, I decide to lighten up our interaction. “Would it still feel good to walk a little more?”
“Yeah, I’m all fidgety, I just can’t sit down.”
“That’s fine, take as much time as you need.”  I pause, relax and sit back in my chair. In a matter of fact manner, I continue with our original process, “So, you were giving me an overview of your life. I think we were at age five. Can you tell me what happened next?”
To relieve some of my client’s anxiety, I chose to bypass the subject of her mother’s death. There will be many more opportunities to explore this material. I also backed away from the intensity of our attunement, giving my client some needed “breathing room.” I allowed my client to simply “be” who she is at this point in time. I did not expect something different or more from her. However, I did lightly challenge her to connect with her inner impulse or emotion that first prompted her to pace. I wanted to affirm her emotion and need to physically shake out some tension. I wanted her to feel safe. Another woman explains this phenomenon:
I was up and down, all over the map. But my counselor was always the same – consistent. My emotional roller coaster didn’t change her and she stayed with me. That was amazing to me. — Sandy
I resonate with Mother Teresa’s philosophy that it is not so important what we do for the poor and lonely, but that we simply be with them in the midst of their suffering. This tenet applies well to our work with these women. It is the essence of love.
When We “Miss” Her
Once attuned, my clients can be quite sensitive to an emotional shift on my part. Even with the best of intentions, I do fail in my attunement skills. Thankfully, the positive and negative impact of our personhood and behaviors on our client is an essential part of the “realness” they must experience, navigate, process, and integrate into their framework for healthy human intimacy.
For example, I have had many clients catch me as my mind has wandered to what I was going to eat for dinner or what I needed to pick up at the grocery store. They have not hesitated in asking,
“Hey Janelle, are you with me?”
I am honest and admit, “No I’m not. I’m sorry. I was drifting there for a minute. Thanks for calling me back. By the way, it’s not your fault I was daydreaming. It was rude for me to leave you. But I’m back. Thanks for being patient with me.”
I might then pursue the feelings that emerged as they sensed me “leave the room,” or simply proceed with our current content or process. It depends on my assessment of my client’s anxiety as a result of my “abandonment” and their ability to proceed. Sometimes I simply “miss” my client. Once, during an obviously difficult moment for a client, I offered reassurance of my presence and care by sliding my chair a bit closer and leaning forward. She continued to speak. As I observed an increase in her anxiety, I assumed it was related to the content of her sharing. Assuming I was accurately attuned, I reflected her strained facial expression and offered empathy, commenting, “It’s hard to talk about this. I can feel your nervousness and anxiety.” My client abruptly reacted by sitting straight up and then pushing herself back into the couch. Her eyes were bright and large as she announced, “Janelle, you are making me nervous. I’m fine with talking about this, but you are getting too close!” Thankfully, her articulation allowed us to quickly repair our attunement and reestablish safety by creating a bit more distance.
Dr. Daniel Siegel notes, “Unless repair of these disruptions in attunement is undertaken, toxic sense of shame and humiliation can become serious blocks to interpersonal communication.” [15, 16] This is painfully true with my clients. Because their core self is not yet developed and precariously unstable, a breach in attunement with me through my dissociation or misunderstanding, can catapult a woman back into her inner dark hole of despair and heart-wrenching shame of non-existence and worthlessness. A dread of annihilation may surface, overpowering her ability to articulate all that is taking place within her. The best she can do at the time may be to withdraw or shut down.
To repair this level of rupture, I must attune to her current state of emotion, rely on empathy, and be willing to own my failure if need be. To reengage in our original process, my client will have to be willing to “reconnect.” If she is unable or unwilling to remain open so that I can realign with her former inner feeling state, I affirm and respect her decision. I realize her safety has been breached and mistrust ignited. Hopefully, my ongoing patience and compassion will eventually reestablish safety and future attunement opportunities.
When She Wants To Be “Missed”
Many women might unknowingly resist against the warm feeling of safety and comfort often associated with attunement. She fears if she relaxes and simply enjoys the experience of togetherness and care, her guards or defenses may fall and it may still be too risky to drop her defenses. She is still not certain she can fully trust. She does not want to open her heart only to be hurt or disappointed “once again.” Additionally, she may not be ready to feel other emotions that could potentially surface if she relaxes and drops her defenses. It is not uncommon then, for some women to unconsciously attempt to sabotage the emotional connection with her therapist as soon as a sense of safety or trust begin to develop.
Many a time I have relaxed with a client, only to be abruptly startled by a sarcastic or mocking response to my last heart-felt remark. The sarcasm immediately breaks the felt warmth and closeness in the room. I have learned to never interpret these defensive maneuvers as personal or react with frustration or harsh confrontation. Indeed, my client’s defenses provide an excellent opportunity for me to readjust my attunement and empathy to her fear and insecurity. I go where she goes and allow her the freedom to relate and express herself in the best way she knows how. When a woman finally makes a choice to allow herself, perhaps for the first time in her life, to feel safe, to relax, and to begin to trust, you can be assured that you are both on holy ground.
1. Hughes (2004) lists these constructs within the context of attachment therapy with children involving parents and a possible team of therapists. Touch can be executed safely and responsibly in this type of setting. Touch should never be a presumed part of therapy with women with same-sex attraction.
2. Hughes (2004, p. 1).
4. It is an infant’s experience of mother’s attunement and affectual regulation and the infant’s own inner feelings or feeling states that form the primitive core of the self. Masterson (1985, p. 24). In her work with women with same-sex attraction, Dr. Elaine Siegel (1988) notes, “because their mothers appeared not to love them and produced massive failures of empathy, my patients had no way to delineate a stable self” (p. 20, emphasis mine). This disruption or detachment from mother can lead to the overall personality development of what has been called “the empty core.” Walant (1995, p. 10).
5. Siegel (1999, p. 69).
6. Siegel (1999).
7. Hughes (1997); Walant (1995).
8. Walant (1995, p. 122).
9. Walant (1995, p. 103).
10. Yalom (2002, p. 34-35).
11. Often the body is used to relieve or process internal emotions and conflicts. This can be especially true of women with samesex attraction. Siegel (1988) notes “Often this use of bodily communication made for tense, restless sessions. The analysands could find no comfort, or even a comforting and comfortable position on the couch” (p. 40-41). Many of my clients have paced, sat on the floor, laid on the couch, asked to sit in my chair, covered themselves with pillows, thrown pillows, abruptly stood to their feet, etc. When appropriate, the therapist can invite the woman to reflect or even exaggerate their actions to determine their meaning.
12. Karle, Woldenberg, & Hart (1976, p. 84-85).
13. Hughes (2004, p. 10).
14. Siegel asserts that attunement includes the “capacity to read the signals (often nonverbal) that indicate the need for engagement or disengagement,” disengagement being defined as a person’s normal need to be alone and not in alignment with another (1999, p. 70).
15/16. Siegel (1999, p. 25)
Hughes, D. (1997). Facilitating developmental attachment: The road to emotional recovery and behavioral change in foster and adopted children. Northvale, New Jersey: Jason Aronson, Inc.
Hughes, D. (2004). Attachment focused therapy for children, adolescents and families. Booklet from R. Cassidy Seminars, Santa Rosa, California.
Masterson, J. (1985) The real self: A developmental, self, and object relations approach. New York: Brunner/Mazel Publishers.
Siegel, D. (1999). The developing mind: Toward a neurobiology of interpersonal experience. New York: The Guilford Press.
Siegel, E. (1988). Female homosexuality: Choice without volition. Hillsdale, New Jersey: The Analytic Press.
Walant, K.B. (1995). Creating the capacity for attachment: Treating addictions and the alienated self. Northvale, New Jersey: Jason Aronson, Inc.
Janelle Hallman is a licensed professional counselor specializing in treating women who are in conflict about same-sex attractions and emotional dependencies. She is an adjunct professor at Denver Seminary and a former adjunct professor at Colorado Christian University. She is also the founder and director of Desert Hope Ministries, a non-profit organization providing conferences focused on the Biblical perspective of human sexuality. Janelle currently resides in Arvada, Colorado with her husband and 17-year-old daughter.