The Vulnerable Therapist and theEthics of Self Care

One thing that stands out for me from my occasional visits to Twitter is that trauma clients know only too well what their therapists can and can’t bear. They test us to see how safe they really are, in telling us the things they imagine are too bad to tell. Or revealing to us how ‘bad’ they really are. Or both. They need so urgently to stay in relationship with us, not to scare us away.

Of course this is a challenge for us, to bear the unbearable with them, to witness some of the worst things that happen to people, the deepest suffering, the greatest cruelties. Trauma takes us all to extremes that we’d really rather not know about. Our natural defenses kick in, just as they do for the client. And it’s our job, for better or worse, to acknowledge and come alongside.

It’s tempting, in the face of unimaginable pain, to fool ourselves that we have power over trauma, that our theories and techniques will see us through. Of course we need them to anchor us, but as soon as we take a position of power in relation to our clients, we risk repeating a harmful relational dynamic. If we invite our clients to take better care of themselves, and don’t do so ourselves, we are implying that we are somehow ‘more resilient’ than them, and I don’t think that is healthy modelling.

When I sit with a client in a highly traumatized state, I have two choices. One is to stay very focused on helping them to leave the trauma state, using my technical skill and knowledge. The other is to open myself to offer a more heartfelt, human contact. It is when I do this that I pick up the trauma energy, the waves of nausea, the horror, the terror. Of course this is what most changes the quality of the work, and is the most therapeutic support in the long run. I put myself on the line; it’s risky. I don’t want the power inherent in certainty; I allow this suffering human to teach me. And in return, that changes me.

We must never underestimate the impact on us of working with people in dissociated states, who are reliving horrendous terror. We are prone to vicarious traumatization, and do well to reflect how we might contribute to it. Yes. We are in the mess with them, and our responses are sometimes messy, with echoes of our own histories showing up. That’s what having a relationship means! It saddens me to see therapists overwork, get burnt out, stressed, irritable with their clients. It really helps when we can recognize the dynamics that we get caught in, the roles our clients invite us into, the potent energy of trauma contagion, and watch out for how we get caught in them. It is also avoidable.

Of course many therapists have had to deal with their own trauma and that’s part of what informs their practice. Whether or not we have our own trauma history, we are all vulnerable, and that is not a weakness or a lack of professionalism. As Cozolino reminds us, we are wired to resonate with others; it’s part of our physiology. Our interpersonal connections can’t hold out if we are unable to resonate with others, or if we shut ourselves down defensively. Trauma therapists need extra wide windows of tolerance!

It’s certainly been my experience that the more work I’ve done on myself, the more clients have opened up. Some of that work on myself has been in the arena of self-care. I wrote in my book that I make no apologies for going for a walk, meditating, doing some art or having coffee with friends during my working day – it is part and parcel of my work. In fact, I would go so far as to say it’s that piece that my clients pay me for, so that the relationship I offer them is freed up. Time and again I notice that when I am more supported, clients come forward. As a student recently said ‘I change myself and then the therapy changes’.  I imagine that if you stop and consider, you’ll notice the same is true for you too.

Speaking personally, I crave the beauty of the natural world, an inner stillness, my sense of creativity, the delight in the company of others as a real counterpoint to the awfulness of trauma. I choose not to get immersed in it, and have to remind myself daily that there is more to life than this.

I think this is tricky for us in our society. Teaching recently in Mexico, the students got this message far more quickly than those in this country tend to. We are often programmed from our early years to take care of others, to put our own needs second. We live in an increasingly individualistic culture. But what if to look after our own needs is actually looking after others? Aware of the interdependence of relationships, I can’t separate the two. How difficult it is to see that self-care is a resource for the therapy, not for yourself. I am sad, for example, when people on a limited CPD budget say they have to prioritize client-focused training over a nourishing weekend in the countryside. (The Well-Grounded Therapist in June – there are still some places left!)

So I have come to believe that there is an ethic in self-care, which goes along with maintaining safe practice and competence to work. This is the ethic of accepting our vulnerability, of personal responsibility, and self-reflection. And then doing something about it. To my mind, it’s every bit as important as appropriate ongoing training, supervision and personal therapy. Have a wonderful day!

Cozolino, L, 2004, The Making of a Therapist, New York, Norton: 192

 

You, me and trauma

This is the second linked blog about trauma therapy.

Trigger warning

It dawned on me recently that my book is not about trauma but about relationship.  Soon afterwards, I read a statement that relationship is not the issue in trauma therapy. Whilst I agree that it is nowhere near enough to ‘be there’ and listen, I have to say that I profoundly disagree with the comment which over simplifies trauma therapy. My conviction is that a skilful and sensitive relational perspective is central to good practice. Here I offer some thoughts about relationally-focussed trauma therapy.

I maintain that we have to take account of neuroscience to inform trauma practice. It helps us to understand what’s going on, to shape interventions and structure therapy accordingly. Unfortunately, in doing so we run the risk of becoming reductionistic and individualistic. The implication of this is that by ‘over-medicalising’ the problem, emphasising skills and technique, we position ourselves as  ‘doing something’ to our clients, with echoes of their original trauma. Let’s not forget that neuroscience gives us a window into the inherently social nature of the brain – trauma theory and practice needs to reflect this.

Of course not all traumatic events are the same and no two individuals respond alike. But for very many victims (I use the word non-pejoratively), traumas fundamentally damage their relationship to themselves, their way of engaging with the world and with other people. In a previous blog I referred to the catastrophic relational consequences of trauma (What is trauma? July 2015). Trauma is never not relational – by definition it always happens in a context. And so relationships need repair and attention, every bit as importantly as stabilisation, resourcing and regaining control.

Trust is very often a big issue for people coming into therapy to ‘work on’ their trauma; it is never a given.  In addition to basic questions of ‘Am I safe with you?’ it is not unusual for clients to be deeply mistrustful of kindness and attention, love being so often tainted by their history, and they expect some sort of pay-back for being in any relationship. Fearful of being hurt again, they develop all sorts of relational ways of protecting themselves which need honouring and care.

I find myself constantly walking – and sometimes misjudging – a very fine line between being over-intrusive in my interest or how I pose questions, and being neglectful by not enquiring enough. I am acutely aware that in either position I can be perceived more as a perpetrator than a therapist. And equally, I must watch out for the trap of falling into rescuer mode.

One of my relational responsibilities is therefore to set and manage boundaries, so often compromised by trauma and so often tested – rightly so – during therapy. I need to hold my therapeutic authority well. This includes steering the client away from the pull to talk about the trauma, directing the pacing of therapy, being confident in helping them recover from a dissociative episode or a flashback, managing risk and negotiating new possibilities. And here’s another trap – I am not talking about an equal relationship. In the dynamic of the ‘helper’ and the ‘helped’, power issues automatically come into play.

While we need considerable expertise in working with trauma, we need to hold it very lightly, in balance with the client’s increasing choice and control. I can never really know what is best for someone else, I can only help unfold their wishes. This can be a delicate process for someone whose survival has depended on  ‘getting it right’ for other people, or appeasing and regulating others so they won’t criticise or hurt them. So I position myself relationally to differentiate, negotiate and collaborate – not skills which clients suffering relational trauma are very practiced in! A key lies in negotiating the space between us, the relational space.

Following my embodied sense of when I can approach, and when I need to back off, I calibrate my presence in response to my client. Too much or too little of my presence can be experienced as shaming in therapy. Shame is almost universal for trauma clients. I see shame as a cultural and relational construct, arising from the insults, criticisms, comparisons and humiliations of daily life and abusive environments. Shame-filled moments need recognition and exquisite care. Moments of re-shaming need to be voiced as far as the client is able.  I like to take responsibility for my part in any rupture; it’s good modelling but also helps me stay in dialogue and not fall into my own shame pit. Thus we co-create the relational therapeutic space, increasing dignity and autonomy.

In Gestalt therapy we tend to think about such skills and dynamics under the rubric of the ‘dialogic relationship’.  Sometimes this involves difficult conversations, naming the unspeakable or the obvious that has never before been mentioned. Sometimes it involves talking more about processes than narrative. Sometimes, the dialogic relationship involves talking about the immediacy of our relationship, and sometimes it doesn’t involve words at all. I argue that the emotional regulation that is a pre-requisite of trauma recovery is best situated in the context of mutual regulation. Dialogue is always open, receptive, present, involving the possibility of mutual appreciation, understanding and authenticity. It evokes our shared humanity. I really want this for my clients, and I really want it as part of my work.

By placing relationship, both implicitly and explicitly, at the centre of trauma therapy we align ourselves more closely with the traumatised person. This creates the context in which more technical aspects of trauma therapy can come to the fore. In doing so, we move away from a  therapy that is ‘science’ to that which is, at heart, the art of being human together.

No More Excuses

This is the first of two blogs about trauma-specific therapy. Here is a plea for therapists to be well trained in trauma, which links to the second in which I will argue for the relational imperative in this work.

Trigger warning.
I recently joined Twitter as a way of engaging in discussion and new ideas, and started this blog for the same reason. What I have found is a community of people, often abused in childhood, who are desperate to be understood and to find appropriate help. They struggle with the ignorance and frank lack of care of mental health professionals, doctors and therapists, never mind the challenge of being understood by the general public. These are the passionate, vocal survivors, able to speak out of their pain, frustration and sense of isolation; I have no doubt that they represent many who can’t find their voices.  I am saddened, disheartened and humbled in turn by what I read.

We have to listen to these survivors’ voices and validate what helps them. A client told me: ‘It’s all about running. My previous therapists encouraged me to run into the trauma when I all I wanted to do was to run away. You do neither, you keep me in between so that I can stop and look at what I is going on and feel  more in control. That’s why this is working, why I am beginning to feel stronger’.

It is a full 100 years since Pierre Janet, following the thinking of Freud and Breuer, recognised the reaction to trauma as ‘visceral’. It is 40 years since the advent of neuro-imaging studies, and 20 years since Bessel van der Kolk’s seminal paper ‘The Body Keeps the Score’. We have now had over a decade of trauma-specific approaches to therapy and discussion about how to integrate this new knowledge to benefit people who have suffered trauma. And still too many therapists haven’t got a clue, and some do real damage.

And still clients have a long and often fruitless search for therapists who can help them feel safe in their own skin, and still people contact me from across the world, saying ‘If only my therapist had known about your book, I wouldn’t have been so hurt…’  or words to that effect. While these messages touch me enormously, I am not trying to blow my own trumpet. I am saying that something is clearly wrong, and that there is no longer any excuse for therapists’ ignorance.

Once upon a time I didn’t know much about working with trauma and to my continuing regret I made mistakes and ‘lost’ clients. Although my instincts and intentions were good, I was, like many other therapists, trained to ‘run towards’ trauma. Having some specialist knowledge and skills has transformed my work. I wonder how many therapists know why it is a mistake to encourage traumatised people to run towards their trauma? Or why using questionnaires might freak someone out? Or how a trauma reaction is reinforced by telling the story or by asking certain kinds of questions? Or what to do if someone has a flashback in a session, or dissociates? Or how to reframe ‘resistance’ as survival? Or understand how therapy can be truly terrifying for some clients?  Let me try and explain a little.

Trauma therapy requires a quite different mind-set from regular therapy. This is because the brains of traumatised people respond differently; trauma simply cannot be processed in the same way. Trauma therapists need to understand this and choose their interventions accordingly. Trauma therapy needs to be underpinned by knowledge of the neuro-physiology of trauma, and of the enduring effects that are beyond the voluntary control of the sufferer. Therapists working with trauma need to know how to translate this information into the skills of clinical practice. A non-pathologising approach is needed, one which honours the incredible adjustments that are made for the sake of survival under threat. You can’t really work with trauma without getting to grips with the terror that pervades most clients’ lives, their triggers and the fear circuits of the brain. Effective trauma therapy must always include the body, and therapists need to know how to work with embodiment, and the survivor’s relationship to their body. Counter-intuitively, they also need to have a way of conceptualising self-destructive behaviours as positive strategies. And crucially, they need to have a structured model for trauma treatment which involves a phased approach, offering a lengthy phase of stabilisation before approaching the trauma.  More than this, they need to know how to grade and pace the work appropriately. Without this, the risk of running headlong in to the trauma and retraumatising the client remains high.  Little wonder that so many survivors despair of finding the help they need. I have seen and heard of this far, far too often and say ‘Enough already, no more’.

I believe that for the most part therapists and other health professionals are truly well-meaning, but good-will is not enough to heal these wounds. The problem may be that therapists both run towards the story whilst at the same time running away from the suffering individual. I suggest that this dichotomy is itself trauma-generated, located in an unconscious cultural denial of, and fascination with, trauma – and is the one that my specialist training has supported me to bridge. I really don’t know to what extent other factors are at play – personal experience, complacency, disinterest maybe. What I do know is that therapists should not be working with traumatised people without some specific trauma-focussed training – not now that we can do something better.

Given that we have a collective relationship to widespread trauma, I cannot place responsibility solely on individual therapists. Supervisors, usually more experienced practitioners, are tolerating sloppiness. Training institutions really need to up their game in teaching trauma and body work. There are still training courses that do not include any module on trauma, sending people out to work with the general public quite unprepared. The field is not as receptive as it needs to be; is still not listening. This is not acceptable, there are no excuses.

What is Trauma: Life Event, Diagnosis or Experience?

Trigger warning

The word ‘trauma’ has slipped into everyday language in ways that I think are unhelpful for many traumatised people. True, few of us are spared some contact with real trauma at some point in our lives. But it has become too easy to respond to commonplace disruptions to life by claiming ‘It was so traumatic!’ I am not trying to suggest that, for example, having your purse stolen or missing a connection is not enormously stressful, challenging and inconvenient, but these are not usually traumas in a specific sense. A consequence of sloppy use of the word is that it can minimise the real horrors of post-traumatic reactions and reduce sympathy for sufferers. Let’s not forget that PTSD has been said to be one of the most serious mental health issues of our time (Davidson, 2000).

So, what is the difference between disruptive and unexpected life events and true trauma? Firstly, these life events are not usually enduring in their effects – we may be significantly impacted by them but only for a relatively short period of time. True trauma, on the other hand, endures for a very long time, often decades. It is a chronic condition. Secondly, while we may need to make changes in response to life events, we usually find ways of adapting and moving on. Mostly we can make choices about what we need to do. On the other hand, genuine trauma tends to encompass many areas of peoples’ lives and radically alters their physiology, their brain function and structure, even. In these aspects they have virtually no control over their lives. A defining feature of real traumatic events is the sense of threat to on-going life.

One description of the massive impact of trauma that I have liked for many years comes from Judith Herman Lewis’ classic book Trauma and Recovery: ‘‘Traumatic events call into question basic human relationships. They breach attachments of family, friendship, love, and community. They shatter the construction of the self that is formed and sustained in relation to others. They undermine the belief systems that give meaning to human experience. They violate the victim’s faith in a natural or divine order and cast the victim into a state of existential crisis……Traumatic events destroy the victim’s fundamental assumptions about the safety of the world, the positive value of the self, and the meaningful order of creation.’’ With a sharper focus on the body, I have taken the liberty of it putting it into my own words, thus: ‘Traumatic events call into question our basic relationship with our bodies. They breach the attachments of skin, bone, senses, blood and organs. They shatter the construction of the body that is formed and sustained in relation to others. They undermine the belief in our physical existence that is the basis of our  human experience. They violate the victim’s faith in a natural or sacred body and cast the victim into a state of existential crisis. Traumatic events destroy the victim’s fundamental assumptions about the safety of the body, the positive value of the body, and the meaningful order in its creation. Traumatised bodies feel utterly abandoned, utterly alone, cast out of the human and divine systems of care and protection that sustain life’.

What I maintain is that a trauma reaction is not so much about the event that precipitated it, but about the impact and experience of the victim. There is no hierarchy of trauma, though it is clear from research that early childhood developmental trauma causes immense damage and takes a very long time to recover from.

Having said all this, I think there is a grey area between troublesome life events and real trauma. Situations like living in severe poverty or being diagnosed with a life-changing or limiting illness can be experienced as traumatic, most likely because the need for survival comes into play.

I happen to be a therapist who resists diagnosis, agreeing with Stolorow that ‘To attribute the affective chaos ….of patients who were abused as children to ‘fantasy’ or to ‘borderline personality organization’ is tantamount to blaming the victim and, in doing so, reproduces features of the original trauma’. To call people who are so affected ‘disordered’ as in the ‘D’ of PTSD misses completely their sense of injury and their hope for recovery. It is possible to re-frame the diagnostic criteria of the DSM into some short statements, closer to the phenomenology of the victim which can be summed up as : ‘I feel out of control’; ‘I feel unsafe’; ‘I fear I will die’.

The reach of trauma is far further than many people imagine. Let’s not isolate victims further by being careless in how we think and talk about it.

Davidson, J.R.T., 2000, New Strategies for the Treatment of Posttraumatic Stress Disorder, Journal of Clinical Psychiatry, Vol. 61, Supplement 7

Herman, J. L., 1992, Trauma and Recovery: From Domestic Abuse to Political Terror, Basic Books, London

Stolorow, R.D., 2007, Trauma and Human Existence: Autobiographical, Psychoanalytic and Philosophical Reflections, The Analytic Press, New York

The Madness of Medea

Trigger warning.

The setting is gorgeous – a large ancient amphitheatre in Siracusa, Sicily, set back from the sea by just a line of poplars, the sun is going down, and the large sandy stage is prepared for the unfolding of a most terrible drama. I do not need to understand the words of Seneca’s Medea to feel the power of the breathtaking performances, especially the physicality of Medea’s madness. Medea has been spurned by her husband Jason, who has married another wife, and in seeking her revenge for this tyranny Medea murders their two young sons.

I want to be quite clear that I in no way condone such extreme actions, but I neither can I dismiss them. As in all Greek tragedies, the tale holds a truth for us in modern times, which I want to try and unpack a little. I think there is something more commonplace and recognisable in this story. To try to make sense of this I am going to cast Medea in a better light than her actions deserve – unlike Seneca who spares his protagonist no mercy.

The reason for my visit to Siracusa last week was to teach relational and family trauma at the summer school of the Kairos Gestalt Institute, picking up on the themes of betrayal, vengeance, tyranny, and uncontrolled passions represented in Greek tragedies. Whilst there I was interviewed by Italian national television station RAI. One question they asked was about the difference between madness and losing one’s reason, as Medea did. I’m not sure how well I succeeded, but I intended to explain organic illness, in contrast to the response to external events that caused Medea to lose her mind (which can be partly explained as a neurobiological process).

We can see features of relational trauma in Medea’s abandonment, and nowhere is anyone sympathetic to her situation, helping to contain her passion. In her tormented instinct to punish the man who has wounded her so grievously she seeks to regain control of her life. One way of understanding Medea is as a woman rebelling against the subjugation to her husband that has defined her life.  Many mothers have moments of resentment, if not of hatred, of their children, and the constraints they place upon her life. This hatred is not the opposite of love, but goes hand in hand with it. In spirit rather than through her actions, she is also a symbol of an empowered woman.

Medea has conformed to the traditional gendered role of many women, in a society which is fundamentally misogynistic. See how sympathetically Seneca casts Jason as the victim of a woman intrinsically ‘evil’. A classic twist of victim-blaming if ever there was one, which we see replayed in stories of abuse and power. But Medea will be put down no longer. In her determination to wreak her revenge she refuses to be a victim. In my experience as a therapist, the more victims are silenced the greater their rage.

Time and again, I hear examples of children being used as pawns to fulfil their parents’ desires or to deal with their frustrations, expectations and unmet needs. Coupled with a mother’s self-absorption, anxiety or depression (often entirely understandable)  the effects of these dynamics can represent the psychological killing of the child’s spirit, their authentic self and their capacity for autonomy. The essence of Medea’s story remains unchanged across the centuries. To the extent that elements of this are pretty much ubiquitous, we must dispel the myth of the perfect mother.

As I think so often happens with trauma, inner and outer worlds are mirrors of one another. One way of looking at the whole story of Medea is as a representation of our internal ‘selves’. The chorus is the running commentary that we play throughout our lives, judgemental yet passive; the moments of vengeance represent the fleeting secret passions and fantasies we harbour and speak of only in confidence; the all too familiar inner chaos. Uncomfortably, we cannot deny them for they are part of what it is to be human. The children represent both loss of innocence and of potential, the ‘death’ of growth and of hope.

I don’t want to imply that if relational trauma is something inherent in human nature there is nothing we can do about it. I was talking recently to my friend and colleague Emily Skye (@eskyepoet) who invited me to contribute some thoughts on trauma to her blog (recoveringoursexemilyskyepoet.wordpress.com). We agreed that one ‘solution’ to trauma lies in acknowledging our own darker instincts rather than in putting them ‘out there’ in people we can choose to blame, and another is to stay in dialogue, open to the pain of individuals, to put ourselves on the line and suffer with them. I also expressed the opinion that while we need to do everything in our power to change attitudes, it will take a very long time to put a stop to the enduring and complex problems of abuse. These themes are centuries old and thoroughly contemporary.

I cannot pretend to know the answers to these difficult questions. To deny their complexity is to lose touch with reality. I sit uncomfortably with these issues daily, agonise over them at times. While it is no small undertaking to change the social fabric, it is far easier to help individuals recover their vitality and be true to themselves, perhaps something will ripple outwards, perhaps some small cycles will come to an end.

Fortunately, there is much that we can do, and I will leave some of those thoughts for future blogs.

Where I am now

Welcome to my blog, which I start slowly, having only just ventured cautiously into the world of Twitter. At the launch of my book last year I said two things (among others!) that are behind my reason for starting this blog. Firstly, I expressed my opinion – and desire – that the theory I had developed would represent just one point in time of an ever-evolving movement towards greater understanding. I don’t pretend to know it all, and am constantly reworking and growing my ideas. Over the year I have had many fascinating conversations which have sprung from my writing, and in part I want to capture and develop some of them here, as if I might think through writing. But I also know that I think better in company and I really hope that this blog will facilitate more stimulating dialogue.

My second reason for starting to write a blog now is that I said that I don’t want to be defined by my book. I knew already that that was already beginning to happen and to some extent I was right. Where I am now is not the same as a year ago. I do recognise the importance of bringing my book to life through teaching and making trauma therapy more accessible to the countless people who need it, and will continue to do what I am able to meet this need. At the same time I need to move on. I look forward to discovering where this will take me, us.