The daily Post

The Last Word

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.

Psychotherapy for Complex Trauma – a talk to the Perth Complex Trauma Network on 14/October/ 2014

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