All posts by Dr. Jan Resnick

A Comment Article in the last Psychotherapy in Australia journal
My last Comment article is about the shrinking, declining state of the Psychotherapy profession in Australia. But first, a brief word of acknowledgement.

Liz Sheean has done more for the Psychotherapy profession here than any other single person I can think of, and I doff my cap and bow in deep respect, appreciation and gratitude. There has been no other forum for unification, networking and communication better than this journal, the conferences and regular trainings held in capital cities across the country and the bookshop. It is our principle source of a national professional identity for Psychotherapy. And I have witnessed the journal grow and improve in quality over its 20 year life-time. Please join me in giving Liz a standing ovation, she deserves it.

It is nothing short of tragic to lose the Journal especially at this time when Psychotherapy is under attack.

We live in a bizarre world. Every profession recognized in legislation as a health-care provider is GST-exempt, from Homeopaths and Masseuses (and I mean no disrespect) to Social Workers, Occupational Therapists, Doctors, Psychologists, and Psychiatrists. But Psychotherapists and Counsellors are somehow omitted. It is unbelievably discriminatory for the playing field to be so off-kilter such that we have to collect 10% of our fees for the government who use it to subsidize Psychologists and other mental health practices, against us. Talk about uncompetitive practices!

Meanwhile, the Psychology profession has mastered spin and branded themselves: ‘evidence-based’ – it’s primary marketing slogan. A radio ad just aired urges us to learn how to re-wire people’s brains by studying Psychology at uni. Meanwhile, my practice is largely filled with patients who have not benefitted from CBT or other government-endorsed psychological practices. This is a constant theme and a distressing one. The Psychology profession is operating more like a powerful corporation that serves its own share-holders or stake-holders even at the expense of its own clients.

Much as I like mindfulness, there is a lot more to therapy than inviting people to be in the present, or meditate accordingly.

As an experiment, I searched for an appointment with a Psychotherapist locally on Health Engine: I was offered a choice of 6 Psychologists, 5 Counsellors, 1 Social Worker, 3 GPs or 10 Psychiatrists. Practically none have had what I would call a full Psychotherapy training or identify primarily as a Psychotherapist. The title “Psychotherapy” is not protected and is now borrowed by other professions. We are a stolen generation of Psychotherapists who are losing the professional identification that differentiates and distinguishes us.

Health Funds are obviously businesses that do their best to avoid paying rebates. I have had a Medibank Private provider-number thanks to PACFA since July, 2012, and not one single patient in my full-time practice has succeeded in claiming a rebate, ever. In fact, it has been a fiasco, pissed-off patients – many of whom stopped coming as a clear result. I am doubtful of the value of getting into bed with Health Funds anyway but their support of other practices makes ours more uncompetitive.

I do realize that many people in our professional associations have worked tirelessly to support the professions of Psychotherapy and Counselling. I acknowledge this. However, it has increasingly become a major hassle and expense to fulfil professional development requirements that do not serve me well, or at all. The associations have become adept at making submissions and doing research while becoming more bureaucratic and pedantic about our requirements. We need direct support, not more rules and requirements that don’t actually serve us well. THIS DOES NOT MAKE PSYCHOTHERAPY MORE CREDIBLE TO ANYONE – rather it drives members away.

Meeting requirements has taken time and resources away from my practice. Of course, I agree with PD and supervision, but I refuse to attend things just to accumulate numbers of hours to fulfil requirements, as I see so many colleagues doing.

I am bitterly disappointed with the decision not to challenge the GST legislation. I do understand the legislation leaves us no way in to challenge it, as written. I’ve studied it myself. BUT the fact that we are discriminated against in such an obvious way by an utterly uncompetitive and prejudicial policy is reason-enough to mount a challenge on those grounds. And this is precisely what we need an association for. A successful challenge here would benefit our practices directly, more than all the studies and submissions rolled up together.

Meanwhile, I am aware of many who are leaving the profession or opting to obtain further qualifications in Psychology, Social Work or Mental Health not out of genuine interest but as a failsafe to fortify their position as a viable professional.

So, what are we going to do about it? Are we going to just dwindle away until we die, and hope something is re-born from the ashes??? Or are we going to stand up and be counted as serious, competent and effective professionals (and make a living from our work!) in our own right???

This is what I’m doing about it.

Psychology identifies as a short-term “problem-solving” approach. But complex trauma survivors need neither a solution to a problem (which trivializes it) nor a short-term approach. Complex trauma requires long-term, in-depth Psychotherapy in the way that many of us have been trained. And complex trauma survivors also urgently need to be treated by professionals who have had a significant and thorough experience of their own personal therapy, as Psychotherapy training requires.

One of the strongest endorsements in recent times for Psychotherapy has been the publication and wide distribution of ASCA’s important manual The Last Frontier, subtitled Practice Guidelines for Treatment of Complex Trauma and Trauma Informed Care. Read it. Go to asca.org.au (if you get the Australian Shepherd Club of America – that’s not it!!). If you go from the Home Page to Resources and then Publications, you can download it for free or buy a hard copy. Of great importance to Psychotherapists is the emphasis on a longer and deeper, and more sensitive approaches to complex trauma, than Psychologists are typically trained to deliver. Trauma Informed Care reflects “practice-based evidence” more than “evidence-based practice” and brings better outcomes.

Based on my own practice-based evidence of nearly 40 years, about 80% of patients have suffered complex trauma, and some don’t even know it! This is where our training and experience affords value to patients especially if we take on board the necessary revisions to traditional insight-based practice, namely the primacy of the body and physical experience generally. And there are now many excellent texts that develop this theme, Ogden & Co, van der Kolk, Levine, Rothschild, Briere, Shore, Shapiro, Atkinson, Courtois & Ford, etc. And guess what? The Last Frontier has condensed and summarized much of it, done your homework for you.

One of the most important points is this: ONE SIZE DOES NOT FIT ALL.

Psychotherapy is an improvisational art whereas Psychology is focussed on generalities. Yes, there are ways that we are all the same, and Psychology works accordingly through its highly standardized methodologies. Psychotherapy is the science and practice of individual differences; it is scientific in the sense of a systematic body of knowledge. But even if you had read every Psychotherapy text ever written, you wouldn’t necessarily know exactly what to do when the next new patient walked through your door. You might know what not to do.

This is because we HAVE TO get to know each patient as a unique individual and we HAVE TO get to know how our patient is different each and every time s/he comes for a session. Our practice fits our patients, as they are, at that time. Psychotherapy does not require patients to fit our practice other than the standard professional frame. Psychologists already know what they will do before the patient arrives. (Personally, I’m allergic to questionaires.) This is not best practice for complex trauma (nor quite a lot else, in my opinion).

So, I am developing my work around complex trauma and its post-traumatic consequences and supervising others, including two firms of lawyers working with trauma survivors. I am supervising Developmental Paediatricians who work with trauma, of both children and their parents, and of course, autism, ADHD, and specifically developmental issues. And I am supervising Psychiatrists and Registrars (in Psychotherapy) who are also at the coalface of treating the most disturbed patients. There is much interest in the new Complex Trauma Network, part of the Mental Health Professionals Network, also an ASCA initiative, in part. And maybe, just maybe, Psychologists and Psychotherapists can realize that we could learn a good deal from each other, if we can survive in the most adverse professional climate I have ever known.

So, my advice after 20 years of Comment articles is: adjust your focus, take responsibility for your own professional destiny (because no one else is) and position yourselves to make a difference where you can.

And I wish you all GOOD LUCK! (It’s a jungle out there). This is my last word: THANK YOU, LIZ! And thank YOU ! – as readers must a writer make.

Can I begin by asking: how many people have read theASCA Practice Guidelines for Treatment of Complex Trauma and Trauma Informed Care and Service Delivery called THE LAST FRONTIER? (please raise your hands)

And another question: I wonder how many people feel confident to treat complex trauma competently and effectively? (please raise hands)

Or I wonder if your answer would be any different if I put the question like this: if a patient were to consult you, saying that she or he had been regularly abused as a child and continued: I don’t really know what the consequences of that have been ever since however

• I have always struggled to connect with other people,
• sometimes periods of time disappear – I don’t know where
• I find sex difficult, I like it but I often think I should really be feeling more,
• Depression is never far and I get terribly anxious, often for no reason,
• and fearful –
• I feel easily threatened sometimes by the most innocuous comment,
• and I am so insecure,
• and suspicious: I expect to be betrayed.
• And so I have to be so vigilant, like my radar is always circling.
• I never really feel safe.
• I have terrible nightmares and sometimes wake crying out or even screaming.

There’s more but do you think you can help me?????   (please raise hands)

It’s hard for anyone to feel very confident.

Just so you know who the speaker is: I want to say that I find professional identification a little difficult.  I have a long background in psychoanalysis and psychodynamic therapy.  In the ASCA document and the complex trauma literature generally there are frequent references to “traditional insight-based therapy” and that certainly applies.

There are elements of psychoanalysis that I love and have a deep commitment to in practice, and there are elements that I hate, and feel deeply critical of, mainly of classical psychoanalysis, not relational psychoanalysis – largely on theoretical grounds.

So, I just call myself a psychotherapist.  Really, my orientation is primarily phenomenological but because people tend to either think of that as a research methodology or don’t think of it at all – I don’t usually refer to it.  But it is phenomenology as a philosophical attitude that has tremendous clinical value for me.

So, I’m a psychotherapist who is taking on board the revisions that are widely recommended with respect to the body, and the primacy of the body and physical experience generally in the therapeutic work with complex trauma.

And that is mainly what I want to talk about – clinical work with complex trauma.

Across all the professions, I expect there is no argument that complex trauma brings massive damage, developmental arrest and perceptual distortions, in its wake.  The challenge for the therapist is how to help survivors recover, how to facilitate healing, how to repair the damage, overcome dissociation, how to improve emotional self-regulation and how to change insecure attachment patterns, or more often disorganized ones to more secure, connected ones.  Obviously, this is a very tall order for anyone.

Typically, those who have experienced complex trauma have become organized around the impossible dilemma of how to survive when their situation was unbearable, overwhelming, couldn’t be processed and couldn’t be coped with.  Often they are left with a deeply-rooted sense of shame at the core of the self, some feeling of responsibility, and often severe doubts about themselves.  It’s so hard to ever feel confident and self-assured with complex trauma in the background.  Those very survival strategies that originated as something of a solution or, at very least – a response – become “the problem” in the ongoing present and future.  Even to call it “a problem” risks trivializing it.  What we are really referring to is a way that a person becomes who they are; these experiences are largely defining.

One way the psychoanalytic literature puts it is like this: “we do not treat patients to cure them of something that was done to them in the past; rather we are trying to cure them of what they still do to themselves and to others in order to cope with what was done to them in the past.” (Bromberg P. 237)

So, the therapeutic task is nothing less than a substantial re-orientation and re-calibration of the patient’s entire character organisation.  It’s pretty difficult to feel confident as a therapist in the face of the Mt Everest of therapeutic challenges.

The good news in the ASCA document is that highly positive results are achievable.  But this means two things, in my opinion: 1) that the therapist is well-versed in trauma informed care and 2) that the patient recognizes that they have a lot of work to do which will take time, possibly quite a long time.

So, long-term, in-depth, trauma-informed therapy is required.  And there is a third thing: I don’t see how anyone can do this kind of work well without having had quite a lot of personal therapy themselves.  That is fundamental to the ethos of psychoanalytic therapy and a central and required part of training in it.

Unfortunately, there are many mental health practitioners of various orientations that do not see the need for this or it is simply not a part of their training or professional sensibility.  Years ago, when I was involved in running trainings – which I did for 18 years – one student who worked as a mental health nurse showed a psychiatric colleague a leaflet in which I had written something like the Director of Trainings has had more than 15 years of personal therapy, and her colleague was appalled.  He said: “What! Why has Jan Resnick had so much therapy?   WHAT’S WRONG WITH HIM????                           And why is he bragging about it????”

Well, this is just a completely different way of looking at things.  If you are going to work with patients who are extremely disturbed, then you are going to be affected by that.  And you don’t have to have suffered complex trauma yourself for that to be the case.

If you’re not affected at all, then how are you ever going to help anyone?  Again, I recognize this is quite a different perspective than in some professional circles.

The point is not for us to be immune to the suffering of others but how we process the ways we are affected and how that becomes a part of therapeutic work.  My experience is that this work can be devastating or amazingly rewarding.  My experience is also that the way that we process our own affects makes a positive difference to the efficacy of the therapy.

But to think we can treat complex trauma with short-term approaches is a joke.  I really don’t want to be offensive to CBT, or to mindfulness practice, or any other approach.   And it’s not that I don’t think these things are helpful.  I hope a single session with a complex trauma survivor is helpful.  Occasionally, we even hit a bull’s eye in a single session.  And I have a patient at the moment who is being helped by a CBT group (even if privately, to myself, some of these groups looks like a gross bastardization and corporatization of therapy and entirely motivated by their potential for profitability).  And mindfulness is awesome.  If we could all be more mindful, then the world would be a better place.  Of course!

It’s just that when it comes to complex trauma, I hear routinely: I would if I could, mate.  Be in the present, yes – absolutely.  But the whole point is that I can’t.  I am preoccupied with something.  Maybe it happened a long time ago but it has infiltrated every aspect of my life, my body, my thoughts and my emotions.  The past is all too present and that is the trouble.

We have to remember that one of the consequences of complex trauma is that time becomes frozen.  The distinction between past, present and future dissolves away.  Traumatic experience is easily triggered and re-experienced as if it was happening again, right now.  Mindfulness may well be helpful and of course it is a practice but is unlikely to be enough on its own to work-through complex trauma and its residual consequences completely on its own.

And I have a concern that mindfulness is sometimes practiced because it is easy and perhaps the practitioner doesn’t really know what else to do.  Then it becomes a band-aid for a gaping and long-standing wound.

One of the most important points in the whole ASCA guidelines document is this:  ONE SIZE DOES NOT FIT ALL.

So, what does this mean?  How can we be confident about working with complex trauma survivors?  Cathy Kezelman, the President of ASCA, referred to me as an expert in complex trauma, and I had a big reaction to it.  And it wasn‘t good.  I said I would never hold myself out as an expert in this field precisely because one size does not fit all.  I don’t really see how anyone can be an expert.

We can be knowledgeable about trauma, about dissociation and we can even be experienced in working with complex trauma survivors.  We can read heaps of books on it, and should.  But when the next patient walks through the door, that doesn’t mean we know exactly what to do.  It might mean that we know what not to do.

For me, psychotherapy is an improvisational art.  This is why the ASCA document is critical of evidence-based approaches: here is a quote from page 81 toward the end of it:

“Just as the DSM remains inadequate in its classification of complex trauma, so do standard ‘evidence-based’ measures of what constitutes effective treatment also require re-consideration.  For this reason, the contrasting formulation of ‘practice-based evidence’ and emphasis on client outcomes rather than pre-determined ‘one size fits all’ treatments, present powerful alternative measures of treatment effectiveness.”

A young patient consulted me recently, I’ll call her Mary. She said that she was having ECT for major depressive episodes, it was the only thing that stopped her from wanting to kill herself.  Then she fell silent for practically the whole session.   I had a strong intuition that she had been sexually-abused as a child though she never said so.  Something inside me said ‘let her be’, ‘don’t interrogate her’.  She seemed rather dissociated, not really there for much of the time, there were a few whimpers, she seemed regressed at points, childlike.  At the end of the time, she said: talking about it makes it worse.  And I said: I suppose that’s why I didn’t ask you the million questions I had in my head.

I am not holding this out as best practice, certainly not expert.  Who knows how to help someone like this?  She has already had over 2 years of therapy with a psychiatrist, and some months of therapy with another, before me.

The ASCA guidelines are excellent, but they are just that, a manual of useful principles.  There is no book and no training that can say unequivocally how to practice clinically with precision and definiteness.  There are road maps but when it comes to something as complex and personal as complex trauma, the map is not the territory.

I approach each case with a fresh attitude, with a view to getting to know this individual patient, how she feels, or what he needs, what works and what doesn’t.  That is the phenomenological attitude in practice; it’s essential feature is to privilege the experience of each patient as the primary focal point.

I do feel confident looking back that I have been just the right therapist for some patients and perhaps not for others.  One patient, Jack, was referred to me by a psychiatrist who had done therapy with him for 2 ½ years twice weekly.  He had made serious suicide attempts and made a very bad one just before.  He was extremely disturbed and possibly the worst case of a spider phobia ever.  All he thought about was spiders.  First thing in the morning, he would check his bed, look under the bed, check his shoes before putting them on.  He looked for them everywhere, he thought about spiders all the time.  Walking down the street, he might stop and check his shoe, just in case.  And he was terrified of spiders.

His psychiatrist had set out to understand this phobia.  He had a psycho-dynamic orientation and so knew it meant something.  Maybe it was a symbol.  Maybe a spider is like a hand, maybe a spider represents some creepy part of ourselves, maybe it is the word that means something, something to do with spying or being spied upon, and so on.  The psychiatrist referred Jack to me because he felt he wasn’t getting anywhere and he was getting frustrated.

So, Jack came and I heard all about spiders, all he talked about was spiders. I asked him directly what spiders meant to him but he didn’t know, he just said that it is the first thing that comes into his mind in the morning, the last thing at night, he dreams about them and thinks about them during the day.  I said: okay, fair enough.  Let’s just take one moment and NOT think about spiders – what is the first thing that comes into your mind?

And without missing a beat, Jack said: Oh, I think about my father sexually abusing me every day of my childhood and then I want to kill myself!

So, this is what I mean by a survival strategy.  We need to find a way of speaking about the unspeakable, or we need to find a way of working therapeutically where we don’t actually have to speak about what was done, perhaps in a childhood like Jack’s.  The function of Jack’s spider phobia was a highly effective way of avoiding what was done to him.  He didn’t need the meaning of it to be analyzed and he didn’t need it regarded as an error of thinking to be corrected.  He needs to find a way of living in the light of, or rather the darkness of, his history.

In the last issue of the national journal Psychotherapy in Australia there was an article reporting on a phenomenological research project about what works and what doesn’t work in counselling for trauma.  I was interested to read that some patients felt aggrieved with their counsellors because they were being pressured to talk about what had been done to them, their traumatic experiences.  They felt they were re-hashing memories without therapeutic benefit.  Other patients were aggrieved because their counsellors weren’t receptive enough to their need to talk about what had been done to them.

Some needed to talk about it and some needed not to.  One size doesn’t fit all.

On the point about how traditional insight-based therapies need revision to work more effectively as trauma informed, I will extract from the Pat Ogden book Trauma and the Body, an example of a session.  (P. 170)

“After several years of successful therapy, Jennifer walked into her therapist’s office and experienced an unidentified stimulus triggering her “freeze” sub-system.  Her body became tight, her eyes cast downward, her arms crossed in front of her, and she thought her therapist was going to hurt her.”

… “Her (male) therapist empathically acknowledged her feeling, reassured her and expressed both his concern and his curiosity that she would think he might hurt her.  While her defensive system was still mobilized (this refers to her freezing up), he gently encouraged Jennifer to activate her exploration system: He asked if she would be willing to orient toward him and notice what happened in her body.  She began slowly bringing her gaze toward the therapist and immediately reported feeling more frightened and paralyzed.  Almost simultaneously she observed that she was unable to feel sensation in her body.  … Jennifer’s attention shifted from “having” her experience to observing it.”

To me, this shift is very important.  She is re-experiencing trauma in this moment and while so much of my work is trying to help people be “in” their experience, be present to it and emotionally engaged, here we have an example of almost the opposite – helping Jennifer to step sideways so that she can look at her experience and not be debilitated by it.

Her therapist expressed his interest and surprise at her reaction, given their years of working together, but he did not try to talk her out of it, … (Now this I find interesting-) He asked Jennifer where in the room he might sit that would feel “right” to her, or at a safe distance from her.

We might say that this is mindfulness in action – he is asking her to be in the present and to consider something of her defensive needs in this moment.  He is also handing over control to her which is bound to make her feel safer, and at ease.

Jennifer asked him to move to the other side of the room, and as he did so, she noticed that she calmed down.

My entire experience of practice tells me that accommodating patients within reason and within professional boundaries and limits often works better, than to be unduly afraid of colluding is some way, most of the time even if not all of the time.

… Through this re-orientation and control of the physical distance, Jennifer no longer felt that her therapist was going to hurt her.  It was only then that she was able to identify the trigger: her therapist’s sweater.  Jennifer’s rapist had worn a similar sweater.

I must say that I had a similar experience once with a patient and I don’t think I handled it as well as this guy.  I think I wound up somewhat traumatized by the patient!   Anyway, it gets more interesting.

As she could sense her body again, Jennifer noticed that the tension of freezing was quite painful.  With guidance, she explored this and her arousal increased again.  She related the freezing to feeling unable to move to protect herself.  Just thinking about her past trauma brought up the freezing.  The therapist asked her if the tension in her body could guide her into a physical action that felt “right”.  She noticed an impulse of wanting to make wide circular motions with her arms which she described as a way of saying: this is my space, you keep out.  He encouraged her to notice how this action changed her internal organisation of experience.  And she noticed the tension lessening and a feeling of satisfaction.  She grew to understand the freeze response as her body’s way of communicating her need for a personal boundary.

This is what I mean by ‘therapy as an improvisational art’.  There is no way of anticipating that your jumper is going to trigger a trauma reaction in a patient.  There are no texts or guidelines to tell you how to work with that.  I don’t believe there is exactly Best Practice or Quality Assurance in this business.  We probably can say what not to do though.

In this example, the therapist is working with his patient to remain within what Ogden and Co have called the Window of Tolerance, a concept I find valuable.  Jennifer is being drawn out of an aroused state, the Window of Tolerance is the middle ground between hypo-arousal and hyper-arousal.  And we can speak more about what happens when the limbic system is triggered or when the Amygdala starts firing.

This is also an example of dissociation.  Jennifer couldn’t just say, “oh fuck – that sweater you’re wearing is a little too close to the rapist’s for comfort.”  The sweater as trigger is split-off from consciousness and hence from understanding what it represents.  The frozen state is one where it is impossible to think, to feel, or to move.  She is also dissociated from her usual association with her therapist with whom she has a positive professional relationship.

So, terms like “processing” refer to working out what things mean, and terms like “integration” mean enabling these meanings to be part of the smooth flow of your experience.  The sweater doesn’t have to come between us.  The past sweater of the rapist is not the same as the present sweater of the therapist.  If you are psychoanalytically-minded, you might say there is no transference reaction.  Or if you are au fait with brain science then we can understand vertical integration as being the inter-connectedness of brain stem, limbic system and cortex (or in ordinary language, physical sensation, feelings and thinking) or we can understand horizontal integration as left and right hemispheres working together.

I know that neuro-science and plasticity is all the rage at the moment.  For me, I’m glad we have a scientific endorsement of the ways that positive experiences and connecting meaningfully in and through a professional relationship over time actually achieves healing, recovery and development.

Understanding this is great but practising is still a mine-field.

As much as I am in agreement about the value of a structured approach, sometimes it does happen, that safety and stabilisation, processing and integration can all happen in a single session.

The Jennifer example also shows what is meant by bottom-up as opposed to top-down, top-down being that we work with our thoughts that lead to our feelings and then the body.  Bottom-up starts with the body and works through feelings to thoughts such as why does this sweater trigger you.

I think handing over control to Jennifer can be seen as an example of empowerment, which made a huge difference and almost certainly enabled her to realize that this situation in the present is completely different to that situation in the past.  You can see ASCA’s 5 qualities of safety, trustworthiness, choice, collaboration, and empowerment all at play in this example.

And lastly, as far as Jennifer is concerned, if you recall – the very first thing I said in giving this example was: after several successful years of therapy – when my patient was triggered – she had attended sessions for several weeks.  Jennifer had several years of a professional relationship as a context through which to work through her freezing up with her therapist in this moment, and was able to do so without falling out with him or her running out of the room screaming, or accusing him of something.

My common experience is this: I can say something to a patient in the first session and it may be on the mark, they may go away and think about it and they may come back and say it was valuable.  Two or more years later, I can say exactly the same thing, word for word, and find it has immense power, it goes way beyond insight to having a transformative potential.  I’m not saying that happens all the time.  But the point is that the communication is not just something with objective content that you can read in a book and expect to have the same effect.  The communication comes from a therapist who has grown to know you well, and has explored the detail of your private experience in depth.  The communication is a function of a deeply intimate professional relationship.  And that makes it a completely different communication even though the words are the same.

I know self-help books are popular but I really don’t think they could possibly do the same job as the inter-personal connection of working with a therapist.

I want to finish up with a word about forming a network.  I’m glad so many people responded to the suggestion.  I know we are a diverse group and that different professions are represented and different orientations within the same profession.  So, what do I want from a network of professionals?

I can easily say what I don’t want.  I think more professional people are traumatized by each other than they are by their patients.

I’ve expressed some opinions and made some assertions about therapy.  I really don’t mind if you don‘t agree with me, if you see things a different way, if you are critical of my ideas or even if you think I’ve got it all wrong.  All that is fine with me.  What I would prefer, however, is for you to tell me directly or, if you would be more comfortable, send me an email.  I am janresnick@amygdala.com.au

What I would like to avoid can be exemplified by an experience I had last week.  A 30 year old complex trauma patient came in for a one-of session.  She has worked with me on and off over the past 12 years. She works for a professional organisation in the regions up north who sent her to Perth for an assessment with a psychologist following a problem with her boss.

She says two things about me: 1) that I saved her life and 2) that she has consulted all manner of professional people but our work is the only thing that has helped her.

She told me that when she had her assessment, the psychologist told her that Jan Resnick doesn’t have any qualifications.  She seemed uncomfortable telling me and wanted to know why someone would say that about me?  Her husband was with her in the session and he doesn’t know me so well and he looked concerned and even more uncomfortable.

I said: I don’t know, maybe she thought that only registered psychologists have qualifications that are real.

Leaving my feelings about this kind of thing aside, I am very concerned indeed that my patient’s faith in our work together should be undermined.   And I’m sorry to say that this is not an isolated example.  It is just a very recent one.

I don’t want to close this on a sour note.  Complex trauma typically causes horrendous suffering.  It is hard enough for therapists to help their patients without having to deal with destructive acting-out from their professional colleagues.

So, I want a professional community that supports each other in this vital work.

We are all here in the service of trying to help patients who have been through hell and probably still are.  When I was training therapists, I described therapy as a practice of thoughtfulness and compassion and I hope we can practice that way to our patients and toward each other.

I want to think critically together.  I think we need to look at things from different points of view and learn from each other, discuss, debate and cultivate a healthy discourse on complex trauma.  I’m pretty sure no one has the last word on how to do this kind of work.  I would just ask that we keep it respectful.

So, let’s keep an eye out for any tendencies toward professional envy, competitiveness or shadenfreude.  My experience is that professional life is too easily contaminated and I have heard over the years from countless other professionals who have been traumatized by their colleagues.  So, let’s talk about trauma without doing it to each other.

If there is one thing Complex Trauma teaches us, it is how easily and how profoundly we affect each other, and how long-lasting that can be.  So, I will leave you with this thought:

If you can start the day without a hit of caffeine or meds to get you going,

If you can be consistently cheerful despite aches and pains, or financial, emotional or other worries,

If you can resist whinging and moaning and telling everyone your problems,

If you can overlook when loved ones are too busy to pay attention to you,

If you can shrug off when people treat you badly or make offhand remarks,

If you can deal with tension or stress without professional help, or alcohol or other substances,

If you can let criticism, blame, accusations or other forms of persecution, deprivation or neglect wash over you, without resentment,

And then, after all that, if you can sleep through the night without the assistance of meds or other aids like a cpap machine,

Then you are probably – – –

– – a dog.

Thank you for listening.

END

Published in Psychotherapy in Australia Vol 20 No 4 Aug 2014

I immigrated to Australia with my family twenty-four years ago. I suppose we were yet another of a long series
of Eurosettlers to arrive here, since James Cook’s first landing some 220 years earlier. Arriving in Brisbane, my
very first experience was unforgettable. We went to the bank in the middle of town to get some Aussie dollars.
There were three Indigenous Australians sitting on the bench outside the bank. When we came out, the police
were giving them ‘move on’ notices, saying they couldn’t sit there.
It just seemed the damnedest thing. They weren’t doing anything. Just sitting. But apparently, this was not allowed,
and not to be tolerated. Since then, my awareness has grown to understand that this is the least of what is not allowed or tolerated.
Things have changed, maybe even improved a little in some quarters, and not at all in others, but the International
community still sees Australia as an extremely racist country.
Indigenous communities are commonly in systemic breakdown caused by deeply entrenched social problems.
There, we find the highest rates of youth suicide, of incarceration, of mental hospital admissions, of deaths in custody, alcoholism, diabetes and other preventable illnesses, of low life expectancy, poor literacy rates — the listis massive. This is unforgivably shameful for a relatively prosperous, first world, highly developed country.
“Australia is the only developed country in the world that is repeatedly condemned for its abuse of its Indigenous
people,” John Pilger says in concluding his documentary lament ironically called ‘Utopia’.
Indigenous people are the original Australians. I understand there is some internal debate as to who qualifies as a truly original First Nations person. It should be obvious there is no race called Aboriginal that is homogeneous, but rather a highly diverse group, with complex social differences in culture, history, language and appearance. The original First Nations were many nations across the country.
I want to understand what it means to be Indigenous in Australia. I really want to ‘get it’. But there are far too many
well-meaning white Australians (yes, I’m Australian now) who want ‘to do the right thing’ for an oppressed people
designated as ‘the others’ and this attitude and practice inevitably becomes patronising, patriarchal and therefore,
demeaning — a perpetuation of the very thing that needs to be overturned for anything even vaguely approaching
‘reconciliation’ to be possible.
On that note, reconciliation is not possible without a treaty. The land of the First Nations has been taken away without a treaty, which has never happened. Such a treaty would, at very least, acknowledge that the relationship to land is central to what it means to be Indigenous in terms of emotional and spiritual health. Native title is a start but not exactly the same thing as recognising original ownership and ongoing custodianship.
Maybe it was because that first experience affected me that the following weekend I bought an artwork called ‘Citizenship’ by Sally Morgan even though its message horrified me — ‘In 1944 Aborigines were allowed to become ‘Australian citizens’. Aboriginal people called their citizenship papers ‘Dog Tags’. We had to be licensed to be called Australian.’

In twenty-four years, I have had one Aboriginal ‘patient’ in long-term therapy for over ten years, on and off. If there is a stereotype, she is far from fitting it. She is a sophisticated, urban professional, well-qualified with a high profile, and a significant salary who holds a position of influence and responsibility.
I have often wondered if I should have a more original approach to therapy for her and any other Indigenous client who might consult me. But would treating Indigenous clients any differently amount to a form of prejudice, in reverse? Yet, shouldn’t we take into account the unparalleled depth of abuse, trauma and mistreatment over precisely the past 220 years for this entire group?
I do treat trauma survivors somewhat differently. But Aboriginal trauma goes beyond the terrible traumas of many
others. It is pervasive, extreme, intergenerational and ongoing. I mean: who in their right minds removes babies en masse from their mothers and fathers? And, according to some reports, the stolen generation that began in the 1920s and was continuous official policy through to the 1960s is still happening (Georgatos, 2014). Pilger in ‘Utopia’ claims: ‘Within a year of Rudd’s official apology, 37 children were removed from their Indigenous families in NSW. In Northern Queensland almost 200 babies were removed from their mothers within hours of birth without a word about process, rights or any explanation why.’

Recently, I was privileged to be invited to a private gig with Steve Pigram playing. So evocative of life in the Kimberley, he sang his original song ‘Crocodile River’:
He’s up a crocodile river on a moonless night,
Trying to shine a light on those beady red eyes,
In a dinghy with no paddle on a turning tide,
At the mercy of a salty, aaaaah — such is life.
The aaaah sounds like a creaky door and refers to the jaws of
a big croc opening to chomp down on you and pull you under,
literally up shit-creek without a paddle.
And to Mimi, his deceased and much-loved grandmother who largely raised him:
Mimi in the Sky, like yellow rays of light, watching over me,
Mimi when she sings, song gliding on the wind, watching over me,
Yawuru1 in my veins, with blood I write her name,
I’ll sing a song to sing what I can say,
Teary Mimi’s eyes, like raindrops from the sky, washing over me.
A voice that speaks so loud, face up in the clouds, watching over me,
Spirit never dies.
1. The Yawuru people are the native title holders of the WA town
of Broome, including pockets of land and sea in an around the
townsite. See http://www.yawuru.com
The next day, we saw the powerfully-affecting film ‘Charlie’s Country’ based on the life of its lead actor, the wonderful David Gulpilil. His character, Charlie, is destitute and anorexic-looking, but despite this gives away his benefit money to others in his community. I found this so confronting, such a different sense of community than the usual out-for-oneself Western variety.
Later, Charlie appears before a white judge with an English accent. Charlie speaks in his native language but the judge asks if he can call him ‘Charlie’ because he can’t pronounce ‘foreign names’. Charlie replies: “I’m a foreigner now, am I?”
Charlie is a poignant example of a contemporary Indigenous person who struggles to live through the old traditional ways in the context of modern Australian society, when those cultural values make even less sense.

I asked my patient: “How do we define an Aboriginal person?” I felt utterly stupid in asking this but then, many Aboriginal people are of mixed ethnicities. I really didn’t know the answer and wondered if it was ‘inappropriate’ to ask. She didn’t make me feel like a ‘dumb-ass white-fella’. She simply replied: “There are three criteria: 1) of Aboriginal or Torres Strait Islander descent, 2) who identifies as Aboriginal or Torres Strait Islander, and 3) is accepted as such by the community in which s/he lives.”
There are variations of this definition used by various legislative and government bodies and many Aboriginal people carry ‘certificates’ from Aboriginal organisations that confirm their identity. But ultimately, it is a white authority that defines who is or is not an Aboriginal person.

Julie Tommy Walker, an Ubbawonga woman and Aboriginal leader has said that without listening to our own voices, ‘Aboriginality’ will continue to be a creation for privileged opportunists and will always be about us, rather than by us.
Even the word ‘Aborigine’ is a creation of English-speakers and originates around 1789, and then grew in common use to refer to Indigenous Australians.
My patient went on to say she was followed around the supermarket by a store detective, expecting her to steal. This happens regularly.

That brings me to ‘dadirri’. Taken from Judy Atkinson’s important book ‘Trauma Trails, Recreating Song Lines: The Transgenerational Effects of Trauma in Indigenous Australia’ which I recommend to you, dadirri is a Ngangikurungkurr word that refers to a deep form of listening to each other, a contemplative process, a quiet,
still awareness. There are similar terms in other Aboriginal languages. Atkinson says dadirri is non-intrusive, ‘hearing with more than the ears; a reflective non-judgemental consideration of what is being seen and heard; and, having learnt from the listening, a purposeful plan to act, with actions informed by learning, wisdom, and
the informed responsibility that comes with knowledge’. (Ring a bell???)
Dadirri involves a strong sense of community. Healing occurs through being listened to, in this manner, over a long period of time. Dadirri requires an empathy that reaches to the sources of pain and anger in the service of generating knowledge and understanding. Meaning here is felt as well as cognised.
Maybe the original approach that is needed is this. We have to change ourselves, in order to effect change in relation to the Indigenous situation in Australia. We change by listening, in some ways as we already do in psychotherapy practice, with our entire being.
For many patients, the agent of healing is not a clever insight, interpretation or piece of wisdom that the therapist might offer. Rather we have to process what has been communicated to arrive at a place of deep empathic understanding. We must overcome the dissociative gaps in the felt-sense of what experience means for the patient through reflection. If we can ‘get it’ then it might, just might, make a difference.

This is not a causal principle. I know I can’t heal anyone. It is more of a principle of attunement, of resonance, of joining up with the experience and history of another person in a spirit of togetherness, of ‘at-one-ment’. As Jung said of synchronicity, it is an acausal, connecting principle.
We, therapists, are working through the damage of our clients. We are working toward a healing of the hurt that has come between us, from the traumatic misdeeds of the past, not least the shockingly wide-sweeping genocide of Indigenous people. We are working to overcome the divisiveness, the alienation, the estrangement, and the defensive distancing that disconnects us and makes a wider, more inclusive sense of community, impossible.
Is this not what is needed of psychotherapy in Australia?
I have worked hard to understand Indigenous experience. I have read some books, seen the films, watched documentaries and even (!) spent a bit of time with some Aboriginal people. Yes, I get it now. I get what so many other white Australians don’t get.

I get that I don’t get it.

So, I will keep on with my own practice of dadirri, and keep listening, and working, to change myself in the hope that one day, the meaning of community can apply equally, to all of us. Then, perhaps we can sit on a bench outside the bank, together.

References
Atkinson, J. (2003). Trauma trails, recreating song lines: The transgenerational effects of trauma in Indigenous Australia. Melbourne: Spinifex Press.
Georgatos, G. (February 15, 2014). Stolen Generations continues but worse than ever. The Stringer Independent News. http://thestringer.com.au/stolen-generations-continues-but-worse-than-ever/#.U92ZtFZVj8u
Pilger, J. (2014). Utopia. See http://johnpilger.com

“Trauma is not simply an individual misfortune.  It is a public health problem of major proportions.

The costs of unrecognized and untreated complex trauma are enormous.  This is not only in terms of reduced quality of life, life expectancy and lost productivity, but in ‘significant increases in the utilization of medical, correctional, social and mental health services.’ In 2007 alone, the cost of child abuse to the Australian community is conservatively estimated to be at least $10.7 billion, and is almost certainly far higher.”

So begins the Executive Summary by Cathy Kezelman, the President of ASCA (Adult Survivors of Child Abuse) of its recently completed and profoundly important document ‘The Last Frontier’ Practice Guidelines for Treatment of Complex Trauma and Trauma Informed Care and Service Delivery.¹  Now submitted to State (NSW) and Federal Governments, it recommends a radical revision of mental health services with a better understanding of the pervasiveness and widespread destructive consequences of complex trauma.

We can often determine the consequences of single-incident trauma by straightforward cause and effect attributions.  Complex trauma is different and frequently confused with Post-Traumatic Stress Disorder (PTSD), a ubiquitous term, even if commonly misapplied.

Complex trauma is repetitive and cumulative and so has been endured on an ongoing basis.  It is generated interpersonally, usually in the context of the family, primary relationships and/or perpetrated by a trusted caregiver.  A betrayal of trust is a central feature which often combines with an exploitation of childhood emotional dependency.  Yet, ‘complex trauma’ is not listed as a distinct syndrome in the current edition of the DSM despite its currency as a significant reference manual in Australia (despite my calling it ‘The Dumb, Stupid Manual’ in the previous edition of this journal).

PTSD is classified as an extreme anxiety disorder that is defined by the event that causes it with symptoms persisting for at least 30 days afterwards by both DSM and ICD-10.  Typically, it arises from an experience that may include the threat of death, something horrific, terrifying or shocking, or perhaps also invasive.

The aftermath of complex trauma may include what we call PTSD but goes considerably beyond it and has important implications for differences in both our understanding of it, its repercussions and hence its treatment.  Complex trauma has far-reaching implications for subsequent mental and emotional development, indeed even physical development.

Ongoing consequences of complex trauma into adult life involve patterns of behaviour and experience that began as normal attempts to cope with an untenable situation in the past.  In the present, such patterns that began as defence mechanisms, become the problem or ‘pathology’ itself that presents for treatment whereas they originated as a solution or survival strategy.

In its simplest formulation, the effects of complex trauma permeate everything.  Patients may find they are easily triggered into states of hypoarousal or hyperarousal.  Self-regulation of the most basic functions of eating, sleeping, urinating, defecating, menstruating are often adversely affected.  Because of this, all manner of secondaryconditions, both physical and psychological, may be brought to doctors for treatment.  Sexual relations are rarely uncomplicated, if even possible.  Dysregulated emotional states are typically amplified and intensified.  Anxiety is pervasive, often extreme and disruptive.  Flashbacks, nightmares, disturbing memories and re-experiencing of traumatic events are not uncommon.  Dissociation, in different degrees and manifestations, invariably follows complex trauma.  Distortions of sense perception occur.  Sensorimotor issues are frequently problematic.  And certainly not least, basic inter-personal relations, the experience of connectedness and a stable relational bond or attachment is fraught and typically insecure or disorganized.

Issues of the ‘self’ are standard; that is, low self-esteem, self-loathing or hatred, self-harm, self-sabotage, and extreme feelings of guilt and SHAME.  The feeling of being a bad person can be almost impossible to shake.  Alcohol and substance abuse are legion, often used as a form of self-medication.  The clinical phenomenology of complex trauma reveals that patients often feel responsible for incurring traumatic abuse despite being children at the time, relatively helpless in the situation and often dependent upon the perpetrator, as so many of my own cases attest.

Trauma-informed Care and Treatment, whether medical, psychological, hospital-based, psychiatric, social, occupational or otherwise must understand how defining such experiences are, how persistently enduring are its consequences and how so much of subsequent development is affected.  While brief interventions might have some limited value, the findings of research into the neuroscience and psychobiology of complex trauma is generating a reappraisal of psychotherapy.  Informed, longer-term and in-depth therapy is required even if it is bound to be a complicated process.  Collaboration between health professionals is an essential adjunct especially since medication may only play an ancillary role in mitigating symptoms.

Now, for the first time in a long time, I am feeling excited about the prospects of a renaissance for long-term, in-depth psychotherapy and what it can offer, instead of feeling demoralized by the dramatically unlevel playing field on which we operate.  There is not a week that goes by without losing a client to free short-term psychology, or other practices that offer genuine Health Fund rebates.  Despite that, I continue to find that people who are committed to their own recovery and development and informed health professionals who understand the value of collaboration enable my own practice to remain lively.

Despite the time and resources necessary, developments in our understanding and application of effective therapy mean that improvements in the outcomes for healing and indeed recovery from complex trauma are better than previously thought.  We now understand that neural networks in the frontal cortex are stimulated by positive social experience and interaction.  Specifically, the production of the neurotransmitters of serotonin, dopamine and norepinephrine are so compromised in depression and anxiety disorders that invariably follow complex trauma.  Here, there is  tremendous scope for psychotherapy to stimulate and repair ‘affect-regulating structures’ through positive emotional experiences so central to psychological health and the feeling of well-being.

Traditional insight-based psychotherapies are learning about the primacy of the body in treating complex trauma.  This means that we do not proceed only from the top-down, moving from cognitive functioning to emotional to somatic but rather from the bottom-up, in the reverse direction.

A phased treatment approach is recommended in the ASCA document, The Last Frontier.  Firstly, a feeling of safety is paramount and possibilities for stabilisation flow from there.  Phase 1 involves setting the frame, boundaries and limits and rapport-building.  In so many ways, we are realizing more than ever that the professional relationship isthe treatment.  Secondly, processing which may represent the most substantial portion of therapy.  This includes the uncovering of what happened, how that was dealt with, what the affects were, and what is still being done in the present as a consequence.  Attending to dissociative tendencies, attachment patterns (often enacted in the patient’s transference to the therapist), and the manifestations of impairment to self-development characterize phase 2 processing.  This leads organically to phase 3 – integration.  Integration has long been held as an ultimate goal of psychotherapy.  It signifies emotional development and also provides a foundation for a greater sense of self-empowerment.

Despite the linear structure, phases are intended as a guide and are not rigid or exclusive.  Therapy will vary from one patient to the next.  Psychotherapy has always been a process that responds to individual difference, and I remain firmly opposed to the universal application of a theory.  While the adaptation to the needs of the complex trauma patient is highly individualized, the ASCA guidelines and the core principles of safety, trustworthiness, choice, collaboration and empowerment are foundational.²

These principles are most achievable when psychotherapy occurs within The Window of Tolerance.³  The idea of The Window of Tolerance comes from Pat Ogden’s Sensorimotor Psychotherapy and aims to identify a middle ground between hyperarousal and hypoarousal with a view to regulating autonomic arousal as we work with victims of complex trauma.  The middle ground is where arousal is optimal, balanced and hence, most tolerable.  This is also what ‘creating a safe space’ means, clinically.

Hyperarousal is expressed as increased sensation, emotional reactivity, hypervigilance, intrusive feelings, thoughts, images, fantasies or memories and disorganized cognitive processing.  Hypoarousal relates to a numbing of emotions, lack of sensation, reduced physical movement and rather disabled cognitive processing, blankness, ‘spaced-out’, remote, cut-off.⁴

Integration also means neural integration.  Convergence of findings from research on the neurobiology of attachment has demonstrated that brain plasticity is profoundly altered by early care-giving relationships in a way that is centrally-formative in the development of a sense of self.  We are increasingly understanding that the way the mind, and even literally, the anatomical brain, is structured and then functions, are very largely shaped and influenced by relationships, especially the earliest emotional ones.⁵  Conversely, the implications for the impact of adverse experience are exponentially worse, even if the implications for healing through therapy are profound.

Over 36 years of psychotherapy practice, I have facilitated the healing and recovery of patients who have suffered so dramatically from the after-effects of complex trauma.   The benefits of effective psychotherapy can be profoundly life enhancing, indeed even life saving.  But it tends to take time, sometimes many, many years, for improvements to be lasting.

Now we have an evidence-base from research that combines with the practice-based evidence of  the clinical experience of psychotherapists, to demonstrate such claims.  It is so important for the broad-based community of medical and mental health practitioners to recognize the need for long-term psychotherapy, and to support it.  Such recognition underscores effective treatment and possibilities for collaboration in patients’ best interest and moves us forward toward best practice.

I recommend checking out the ASCA website at http://www.asca.org.au/ where there is a wealth of information and you can also contact the organization to request a copy of The Last Frontier.

Concluding unscientific postscript: if readers detect a lack of my usual humour here, that is because complex trauma is, simply, no laughing matter.

References

1. Kezelman CA, Stavropoulos PA. The Last Frontier: Practice Guidelines for Treatment of Complex Trauma and Trauma Informed Care and Service Delivery. Adults Surviving Child Abuse. 2012
2. Fallot RD, Harris M (Eds.). Creating Cultures of Trauma-Informed Care (CCTIC): A Self-Assessment and Planning Protocol. Washington, DC: Community Connections; 2009.  Available from: URL link
3. Ogden P, Minton K, Pain C. Trauma and the Body. New York: W.W. Norton; 2006.
4. ibid
5. Cozolino LJ. The Neuroscience of Psychotherapy: Building and Rebuilding the Human Brain. New York: Norton; 2002.

END

Suggestions for further reading:

1.  Arnold, C & Fisch, R.  The Impact of Complex Trauma on Development.  Northvale, New Jersey: Jason Aronson, Inc.; 2011.

2.  Briere, JN & Scott, C.  Principles of Trauma Therapy – A Guide to Symptoms, Evaluation & Treatment.  Thousand Oaks, California: Sage Publications; 2006.

3.  Briere, JN & Lanktree, CB.  Treating Complex Trauma in Adolescents and Young Adults. Thousand Oaks, California: Sage Publications; 2012.

4.  Bromberg, PM.  Standing in the Spaces – Essays in Clinical Process, Trauma & Dissociation.  Hillsdale, New Jersey: The Analytic Press; 1998.

5.  Courtois, CA & Ford, JD.  (Eds)  Treating Complex Traumatic Stress Disorders – An Evidence-Based Guide. New York: The Guilford Press; 2009

6.  Cozolino LJ. The Neuroscience of Psychotherapy: Building and Rebuilding the Human Brain. New York: Norton; 2002.  and others.

7.  Davies, JM & Frawley, MG.  Treating the Adult Survivor of Childhood Sexual Abuse – A Psychoanalytic Perspective.  New York: BasicBooks; 1994.

8.  Howell, EF. The Dissociative Mind.  Hillsdale, New Jersey: The Analytic Press; 2005.

9.  Kezelman CA, Stavropoulos PA. The Last Frontier: Practice Guidelines for Treatment of Complex Trauma and Trauma Informed Care and Service Delivery. Adults Surviving Child Abuse. 2012 – this document also serves as an excellent and accessible summation of current literature. You can request a copy from the ASCA website: www.asca.org.au or from me.

10.  Levine, PA.  Waking the Tiger: Healing Trauma: The Innate Capacity to Transform Overwhelming Experiences. Berkeley, California: North Atlantic Books; 1997.  And the more recent: In an Unspoken Voice – How the Body Releases Trauma and Restores Goodness. Berkeley, California: North Atlantic Books; 2010.

11.  Ogden, P, Minton, K & Pain, C.  Trauma and the Body – A Sensorimotor Approach to Psychotherapy.  New York: W.W. Norton & Co.; 2006.

12. McWilliams, N.  Psychoanalytic Diagnosis – Understanding Personality Structure in the Clinical Process (second edition).  New York: The Guilford Press; 2011.  While not dealing with trauma per se this is the best text to differentiate different types of character organization.  In addition, in this updated new edition, there is an important new chapter on dissociative psychologies of great relevance.

13.  Rothschild, Babette.  The Body Remembers: The Psychophysiology of Trauma and Trauma Treatment.  New York: W.W. Norton & Co.; 2000. And many others.

14.  Scaer, RC.  The Trauma Spectrum – Hidden Wounds & Human Resiliency.  New York: W.W. Norton & Co.; 2005. Also: The Body Bears the Burden – Trauma, Dissociation, and Disease. New York: The Haworth Medical Press; 2001.

Psychotherapists Anonymous
(and the social media circus)
With the advent of the internet, and the rise of social
media, significant and pressing concerns present
themselves as to the average therapist. How should we
promote ourselves to attract bookings? How personally
visible should we be in our use of social media? And how
does that affect the transference?
According to the American Psychological Association,
in a 2010 paper Where has all the Psychotherapy gone?, thirty
percent fewer patients received psychological interventions
in 2008 than they did eleven years earlier. And while talk
therapy has been in decline, Big Pharma has increased its
domination through drug treatments. In 2005 alone, $4.2
billion was spent on direct to consumer advertising and $7.2
billion on promotion to physicians.1
How does a single counsellor or psychotherapist in private
practice compete with that? In particular, in an Australian
context where psychology is subsidised or free?
Many of us were probably attracted to this work in the
first place, at least in part, because of its non-commercial
quality. Now we must think about marketing just to exist,
much less survive.
Theoretically, you could be the best therapist in the world
and no one ever attend your practice. Equal and opposite,
you could be the worst therapist and be busy because your
marketing worked so well. There must be a ‘happy’ medium.
In the US, there is a new specialised industry of branding
consultants who counsel therapists to establish or protect
their livelihoods in the current market.
Did anyone learn how to attract bookings in their
professional training?
What’s worse is that in the more than 22 years that I have
been practising in Australia, not one patient or enquirer has
asked if I was a member of a professional association, if I
subscribed to a Code of Ethics, or worse still, if I was even
trained or qualified!
To the big question of how to promote ourselves, the
answer must be: any way we can. A website is now as
essential as a business card in the past. Then, we have to ask:
how will people find our website? And what are they looking
for?
Driving traffic to a website is a major science, but what
makes it harder is that the rules change, regularly. For
example, it used to be that key words were key. We needed
to do key word analysis, find what people most searched for
(i.e., ‘depression’, or ‘addiction cure’, or ‘trauma therapy’) and
then load up the page with these words. We were (and are)
slaves to algorithmically-driven search engines. Now, key
words don’t matter, apparently.
I just use local-paper advertising. Old school I know, but it’s
something.
1 From a New York Times article by Lori Gottlieb, What Brand is
Your Therapist?, November 23rd, 2012.
What people are looking for, in my opinion, is a person
they can relate to. They want a therapist who is not too formal
but not too casual, boundaried but not remote, visible but not
naked, caring but not gushy, intelligent but not academic, and
experienced but not a dinosaur. They also want someone who
is confident and authoritative, but not arrogant or superior, too
up-themselves.
They want someone who ‘gets it’. We need to think about
how to convey this.
The money often doesn’t matter that much, or if it does, then
they want someone who is affordable, but not cheap. I find it is
better not to advertise fees up-front.
One tip to get below the surface of this iceberg is to check
out Ali Roth, a website consultant for therapists at http://
myshrinkwrap.com. Her tagline is Websites even Freud would
Envy (!) She is Los Angeles-based but even her homepage is
instructive. Her advice: ‘People need to like you when they Google
you. They want to feel an immediate personal connection.’
And what of our use of social media? Along the lines of
personal connection, how far should we take this without
positioning ourselves as ‘friends’?
Social media is an absolute circus these days and we are at
risk of becoming clowns if we use it badly (or use it at all?).
Many therapists shun Facebook. Many don’t care what happens
if you Google McDougal, or you want to tweet Pete. Many won’t
email a female or mail a male, and few want to be in-synch
through LinkedIn. I do wonder though who will be the first
amongst us to open a Weibo account?
That said, a recent Harvard University research paper claims
that self-disclosure on social media sites activates dopaminerelease
in the brain in a similar way to the pleasure we feel from
food, sex or money. Maybe we’re not tweeting enough???
Perhaps most of us were trained that anonymity is desirable,
many of us were instructed to be a blank screen, a ‘tabula rasa’,
ripe for the projections and transferences of patients. We were
told that even our consulting rooms should be as neutral as
possible, nothing that gives away too much of who we really are.
Not even family photos. (My therapist has photos of her dog
which revealed a very great deal about her to me…).
But has the world moved on now? Is this no longer the best
way to work? Are we at risk of being left behind? Is this what
people are seeking when they want a therapist?

Things have changed so much, and quickly. Would anyone argue?
I think Ali Roth is right, people do want an immediate
personal connection. And there is no personal connection
unless we are willing to be a person, and visibly so.

But the question still stands: how visible?
Should we say: Face it, Facebook is a global phenomenon.
And if we want to book ‘faces’ in our practices, we need a
presence there. But should we ‘friend’ clients? Or accept
invitations to be ‘friends’ from clients? How will it be if we
‘reject’ them?
I told one client recently that while we knew some people in
overlapping social groups, and we may well run into each other,
that I thought it wasn’t ideal for their therapy for me to accept
their friend invitation. And how do you feel about that??? Of
course, that was an email exchange.
On the other hand, I wonder how much harm, if any, it
really does to be seen for who we are. Isn’t authenticity still
paramount?
I am sufficiently visible as to be more transparent than probably
most therapists. But I do not want to reveal my own stance on
politics or religion — even if I do on Facebook. Here, practically
everyone hates Julia and no one at all can stand Tony.
God is such a loaded subject. I am very willing to discuss my
patient’s experience of God, or their views on politics, but here I
am as invisible, personally, as possible. But if you want to know
where I’m going on holiday, or that I spent Christmas writing a
book, I really don’t mind.
Does it affect the transference? Of course it affects the
transference. But there is no uncontaminated space. It just isn’t
possible. I used to try in my London days. One patient came in
and said, “I saw you get out of your car. I never imagined that you
would have a car like that”. She seemed rocked, de-stabilised.
The essential point is that we still need to be alert for
transferences, projections, idealisations and de-idealisations, no
matter how visible we are, or how invisible we think we are. And
they still happen anyway.
The patient’s pattern will unfold. I won’t say ‘regardless’
because our visibility does make a difference. We do need to
be aware of what of ourselves has become visible. Better to
be conscious of it, and think about how this will affect our
patients.
Over 28 years ago, the patient who was bothered about my
car nearly had a breakdown (well, she did, actually) when she
found out my wife was expecting our first baby. Even in those
days, it was hard to be opaque. Now, it’s impossible.
The advent of the internet has changed everything. The
geography, demography, psychological ecology, and social
anthropology of the planet have changed and are continuing to
change dramatically. We had better get with the program, reprogram
and change our traditional channel or we will be left
behind. The article quoted at the beginning indicates we already
are. As we said in the 60s, tune in, turn on or drop out (man).
We can worry about the transference, but surely we had
better worry about our bookings or there won’t be any transference.
In that case, see you at the next meeting of Psychotherapists
Anonymous … online.

Jan Resnick, Amygdala Consulting

janresnick@amygdala.com.au

PSYCHOTHERAPY IN AUSTRALIA VOL 20 NO 2

We live in a constructed world built with ideologies that permeate everything right down to our very selves.  Economically, socially, politically, and professionally, we are the rope in a tug-of-war between the interests of our individual selves versus the interests of the group: the local, state, national and global communities.  This ideologically-driven battle has defined diverse political movements over the past hundred years or more in which the very meaning of democracy and freedom is at stake and so has far-reaching implications for our practices.

This article is based on the brilliant 2002 BBC documentary series by Adam Curtis called The Century of the Self, a must see.

Curtis begins with Edward Bernays, who continues to influence corporate America and beyond.    Strangely, Bernays’ mother was Freud’s sister, Anna, and his father, Ely, was the brother of Freud’s wife, Martha Bernays.  So, Edward was a double nephew of his Uncle Sigmund.

Though not widely recognized Bernays was almost as influential as his famous uncle, and regarded as one of the hundred most influential people of the 20^th century.  Bernays was first employed by the American president Woodrow Wilson to disseminate propaganda in Europe regarding America’s war efforts to spread democracy throughout Europe when it entered the first World War.  Bernays was so successful in this that he realized he could use propaganda to influence the masses in peace time.  As ‘propaganda’ was something of a dirty word, he coined the term “public relations”.

His first major foray into sales and marketing manipulation was in overturning the social taboo against women smoking cigarettes in public.  He organised a large group of women to light up during a parade in New York.  When asked what they were doing, they were prepped to respond: we are lighting our torches of freedom!

Notice how emotion is employed in the service of ideology by associating a cigarette with the Statue of Liberty.  Bernays had first consulted a psychoanalyst who, for a large fee, told him that cigarettes were a symbol of male sexual power and if women smoked, they would have their own penises.  If only equality was this easy! (puff puff)

Sales of cigarettes to women grew firmly (like an erection?) but ironically, Bernays later came to regret this, when his wife died of lung cancer.  She wasn’t the only one because it was, in fact, Bernays who introduced his uncle in Vienna to Havana Cigars.  To show his gratitude, Freud gave Bernays a copy of his Introductory Lectures to Psychoanalysis – which greatly influenced him.

Later, when Freud was nearly bankrupt, he approached Bernays for help and so Bernays arranged for Freud’s writings to be published and promoted in the US.

Bernays learned that you can tap powerful unconscious forces and make people behave irrationally if you link products to people’s feelings and desires.  Products could become compelling emotional symbols of how we want to be seen by others.  Ooooh, what a sexy car you drive…

This solved a major problem for American corporations that were afraid that supply could easily outstrip demand because mass produced goods were flying off production lines.  In 1920s America, people still mainly bought things they needed and didn’t replace them until they wore out.  Luxury goods were only a province of the rich.

Paul Masser, a prominent Wall Street banker who worked for Lehman Brothers at that time realized that we must shift from a needs-based culture and train people to desire new things before the old had been consumed.  We must shape a new mentality where our desires overrule our needs.

Bernays, armed with theories learned from his uncle Sigmund, was the person to bring about this shift, with particular respect to what motivates us.  Bernays invented and employed many techniques of consumer persuasion that still inform advertising, marketing and sales cultures today.

For example, he was the first to link Hollywood film stars to products and also to politicians.  President Coolidge was regarded as something of a national joke but Bernays invited a group of famous actors to hang out with Coolidge.  It was picked up by all the major newspapers and suddenly Coolidge was cool.  He dressed the stars in the products of his clients, the corporations.  He employed psychologists to write reports to tell us that products are good for us, represented as independent studies.

The idea that we need to express our hidden, individual selves and show our feelings, moods, and values to the world was born.  By 1927, the press reported that a change had occurred in democracy itself that was named ‘consumptionism’.  Our very responsibility as a citizen became to support the economy (stupid) by being an active consumer.

In 1928, President Hoover announced to advertising and public relations men that they have taken over the job of creating desire and “you have transformed people into constantly moving happiness machines that have become the key to economic progress.”  The idea was emerging that at the centre of mass democracy was the consuming self that made the economy work and made people docile and happy.

The wave of consumption was further fuelled by the Bernays-generated idea that ordinary people should borrow money from the banks (his clients) to buy shares.  But ultimately, the happiness machines crashed when the stockmarket suffered its worst collapse in history in 1929.

Bernays had written a series of books claiming that he had developed techniques to control the masses by stimulating their inner desires and sating them with consumer products, thereby managing the irrational forces of the Freudian unconscious.  He called this The Engineering of Consent (think Noam Chomsky who opposed such techniques, much later).

Following Bernays, mass democracy was being turned into a form of pain relief medication or an anti-depressant (a la retail therapy).  The key to social control is to keep people as passive consumers.

Jump ahead 50 years or so to the 1970s and the human potential movement, ideas of being authentic, being oneself and being present, became employed by American corporations as a way of inducing us to buy things to express our selves.  American-styled capitalism discovers it can ‘get inside our heads’ through questionaires, surveys, focus-groups and a vast industry of psychological market research aiming to develop products to enable us to express our individuality, our sense of being unconventional and even our very sense of freedom.  Find out what they most want, then sell it to them.  (BTW There is now designer-wear available for yoga and meditation).

With the advent of the new self, products and services have unlimited horizons, they satisfy deep emotional yearnings and can make us a better person.  (I confess my Pavlovian heart is in-love with a new car and it is so sexy, I’m drooling!).

Through his giant imagination, Bernays, called the originator of spin and the father of public relations, created a vision of the future as one where we become free by satisfying these individual feelings and desires, now called “needs”.  (I really do need a new car, really.)  These ideas began with Freud, fostered and promoted by Bernays, disseminated by big business and ideologically-celebrated by politicians.  But privately, Bernays believed that democracy could not work because we are ruled by unconscious instinctual drives of sexuality and aggression (Freud) and therefore we must be controlled by a ruling elite.

Actually, we are greedy, selfish, get-what-we-want-at-any-cost-without-care-for-others creatures.  And as Freud said, being even remotely civilized keeps us discontented and wanting more.

The Bernaysian techniques of spin, manipulation and propagandizing were originally developed not to liberate us, but to find new ways of controlling us.  The consumer is king (long live the king?) but consumption is a way of giving us the illusion of control while positioning us to be controlled.

To think outside of our self-interest would involve challenging the dominant Freudian view of human beings as irrationally-driven, a concept advocated by the major corporations to make us ideal consumers in their self-interest.

Curtis concludes: “Although we feel that we are free, in reality we have become slaves of our own desires.  We have forgotten that we can be more than that.”

So, what exactly are we doing with our clients in counselling and psychotherapy?  Are we aware of the ideologies that permeate our practices?  What theories are being served and in whose interest?  Are we freeing people to be themselves, to express themselves, to develop their own identities?  Or are we a cog in a much bigger machine that spins the illusion of freedom while keeping us slaves?

The very feeling of sufficiency has been all but destroyed by the constant bombardment of inducements to buy buy buy.  The century of the self is becoming the era of insatiability unless we can say bye bye bye to our own acquisitive, accumulative tendencies, thereby de-constructing the ideology of a self that has to be wealthy in order to be of value at all.

What if we need to put a lid on our desires in order to be free.

PSYCHOTHERAPY IN AUSTRALIA VOL 20 NO 3

Algorithms are now acknowledged as having a serious edge over human expertise in forecasting the outcomes of a whole range of activities.

An algorithm is a formula that consists of a set of instructions for calculating or defining a sequence of operations.  In mathematics and computer science, algorithms are used to analyse huge amounts of data way beyond the capability of the human mind.

The word ‘algorithm’ was first derived from the name of an Arabic mathematician, Mohammed ibn-Musa al-Khwarizmi, known in the Bagdad royal court from 780 to 850.  So, they have been around for a long time.

If you think there is no relevance to contemporary psychotherapy then you would be mistaken.  For example, one dating website (not that I’m looking) claims that by asking a handful of inane questions that it can predict whether or not a couple will stay together.  One question is Wouldn’t it be fun to chuck it all in and go live on a sailboat?  That beats John Gottman who only needs 7 minutes with a couple to “know” if they will stay together.

We just love to predict the future, we want to know the weather, we seek info from the stars as to what the day has in store for us and of course, the stock market is everyone’s favourite for tips, spruiking the future and crystal-ball gazing.   There have been some spectacular successes, too.

The whole industry of gambling is based on guessing what will happen, and when we’re right, we feel so special.  If only we could do it with Lotto!

We use surveys to forecast elections.  For shares, we have trendlines, stochastics, moving averages, other charting techniques, Bollinger bands, Elliot Wave Theory, Fundamental Analysis, Value Analysis, Cash Flow Analysis, ROI and throwing darts at the shares page in the newspapers.  There are still tea leaves, palm reading, various types of cards like Tarot, and my personal favourite, the I Ching.  And psychics and clairvoyants are very much in demand (our competition??)

The 2003 Complete Idiots Guide to Psychology states that the best predictor of future behavior is past behavior which it claims is “a psychological fact of life”! – Well, it is an idiot’s guide.  However more sophisticated psychologists know that it is not quite this simple and would modify this “fact” with certain qualifications.  The more frequent the behaviour, the shorter the time frame, the more consistent the context, the absence of anything to change that behaviour, the person concerned must be much the same and typically consistent in their habits – all make this fact more likely to be borne out in practice.

The bottom line, however, is that for all our methods and methodologies, we are incredibly bad at forecasting the future with any modicum of reliability.

The psychologist Daniel Kahneman, in his book Thinking Fast and Slow discusses a study of counsellors who believed they could predict the high school grades of their students with all the information available to them about their students’ past performances.  They accessed multiple aptitude test scores, a 4-page personal statement and a 45-minute interview.  Their success was then compared with an algorithm that only had access to one aptitude test and school grades.  Despite ‘knowing’ the students personally to some degree, the algorithm was consistently more accurate in predicting future grades.  (What do counsellors know anyway?)

But there is good news now, algorithms are being developed that cut-through the self-deceptions, the prejudices, and the gut-feel and intuitions of silly humans who think they know something.  Wishy-washiness is dead.

More importantly, this outperformance of algorithms over humans is occurring in virtually every context where human judgements are compared with a formula.  All kinds of complex and formerly uncertain activities are now increasingly predictable with higher and higher probabilities such as how long a cancer patient will live, the credit risk of applicants, recidivism, and of course, the holy grail of forecasting – the share market.  And let’s not forget footy tipping!

Yet, some algorithms are better than others and some are not reliable at all.  I don’t believe the sailboat question above has any meaningful predictive value and dating websites are hardly the best source for scientific rigour.

But it is the dating websites that have increasingly become the way that we meet each other and couple-up, or sometimes just ‘hook-up’.  First launched in 2000, these sites typically claim to have developed complex algorithms to match you with your perfect mate.

Such algorithms are based upon our more than a hundred years of studying couples who are compatible and stay together, then matching profiles and Hey! Presto! – you have found THE ONE.  You are given on a platter your soul-mate, who ticks all the boxes, who will remain faithful and true, and give you beautiful orgasms until Le Grande Mort do you part.

All you have to do now is supply the magic of inter-personal chemistry that no algorithm can predict.  Forgive me for scepticism but algorithms for all their computational power cannot substitute for love, and never will.

You have to be very careful with algorithms.  We know them best from Google, a company that has transformed itself through the use of algorithms into a multi-billion dollar corporate behemoth.

One American marketing company appeared to get it badly wrong when it began sending a teenage girl coupons for nappies.  Her irate father lodged an official complaint.  But later he had to phone and apologize admitting that he was, in fact, going to be a grandfather.  The algorithm analysed her Google searches and knew she was pregnant before he did.

But another company had the clever idea to take the modern meme Keep Calm and Carry On (from the British war-time poster) and use algorithms to create slogan variations to be printed on T-shirts.  It advertised, marketed and sold the printed shirts automatically without even checking what the computer came up with.  Some eyebrows were more than a little raised when Amazon offered T-shirts emblazoned with Keep Calm and Grope a Lot and best (or worst) of all Keep Calm and Rape.

Ultimately, we need to be discerning about how we use algorithms.  Romantic love and the durability of our primary relationships is fair game for the cold analysis of data.  The statistician Robyn Dawes came up with the simplest algorithm that does indeed seem to have amazing predictive powers as to whether or not a marriage will work and last.  Subtract the frequency of quarrels from the frequency of love-making.

A negative number suggests you should consult a lawyer – OR A COUPLES THERAPIST!