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.