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 firstname.lastname@example.org
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.
Psychotherapy for Complex Trauma – a talk to the Perth Complex Trauma Network on 14/October/ 2014 September 19th, 2016Dr. Jan Resnick