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.