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.

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