Care When Working With Trauma
There is a real issue in the world of therapy which I believe needs to be raised and that is the question of whether counselling and psychotherapy courses adequately equip therapists to work with trauma. By trauma I refer to a spectrum of psychological disorders and symptoms such as the following:
PTSD (Post Traumatic Stress Disorder)
Complex PTSD
Borderline Personality Disorder (BPD)
Dissociative Identity Disorder (DID)
Without adequate training and awareness there is the risk that the therapeutic space can retraumatise clients who have endured trauma and/or abuse in the past, as this client group do have different and specific needs to that of many other more typical clients who have not endured similar histories.
With the increasing disclosures around historical childhood sexual abuse more and more survivors are finding that old wounds are being reopened. There is a significant increase in people accessing counselling for sexual abuse.
Many clients who have experienced sexual and/or physical abuse and/or chronic emotional neglect throughout childhood will have difficulties forming healthy attachments. Trust will be incredibly difficult for the therapist to earn and the fear of abandonment can be crippling for this client group. Alongside this the client may be experiencing PTSD symptoms such as debilitating flashbacks of an emotional and/or physical nature where their brain and body perceive that the original trauma is happening right now in the present. There are numerous ways in which therapists can unwittingly retraumatise clients but in this article I will focus on two significant risks.
'I never teach a client to hit the accelerator, before I know that he can find the brake'
1) Prematurely encouraging talking about traumatic experiences
We need to make sure that a client is not being overwhelmed and potentially flooded with feelings of panic and terror when talking about their experiences. It is possible to make a client feel worse rather than better and we need to learn to notice the body language and cues in order to apply the brakes in therapy and to keep it a safe space. Sometimes it is not “good to talk”. I use the term brakes as described by trauma specialist Babette Rothschild who’s book The Body Remembers was incredibly helpful to me and filled some of the gaps that my training did not provide. Here is an excerpt from an article entitled ‘Applying the Brakes” by Babette Rothschild:
‘I apply the same principle to therapy, especially trauma therapy. I never help clients call forth traumatic memories unless I and my clients are confident that the flow of their anxiety, emotion, memories, and body sensations can be contained at will. I never teach a client to hit the accelerator, in other words, before I know that he can find the brake.
Following this principle not only makes trauma therapy safer and easier to control, it also gives clients more courage as they approach this daunting material. Once they know they’re in the driver’s seat and can stop the flow of distress at any time, they can dare to go deeper. Developing "trauma brakes" makes it possible for clients, often for the first time, to have control over their traumatic memories, rather than feeling controlled by them.’
This is where creative therapies can really come into their own. Working through trauma for example with miniatures or art can help clients process painful, traumatic experiences without having to speak of them out loud which might be too overwhelming. Some clients might find writing things down helpful. Animal assisted therapy can really help a client to feel grounded. Basic breathing and grounding exercises can help bring a client back when they start to feel flooded with panic or terror or they start to dissociate. There will be a way to work it through but it needs patience, respect, compassion and for there to be a solid foundation of trust as well as knowledge of the physiological symptoms of trauma.
2) Retraumatisation by reenacting abandonment
Working with this client group will often be challenging and it is tempting to try and do our utmost as therapists to help our clients feel supported and safe. We might stretch our boundaries and offer contact in between sessions via text or email. No matter how positive and healthy the intentions in doing so, the reality is that for many therapists this may not be sustainable. Listening to and empathising with extreme abuse and offering constant reassurance can become difficult, especially if the therapist faces some personal challenges and their resources are depleted. Sometimes clients, especially those with Borderline Personality Disorder may engage in difficult behaviour such as frequent self-harm and suicide attempts. This will impact on the therapist especially if a bond has been built. Sometimes a client’s trauma might tap into a therapist’s own unresolved issues and transference/countertransference muddy the waters. Even the therapist may be unsure of what belongs to her and what to the client. A therapist can feel overwhelmed and inadequate. They might genuinely believe that they can’t do any good for the client anymore, or they may have feelings of anger or feel they just can’t give anymore.
When I researched for this article I asked if anybody had experiences of being retraumatised by therapy. I received two detailed responses and they were both about being abandoned by their therapists. There is real learning for us as therapists if we can listen to and understand the client’s experience of therapy suddenly being cessated. I have been given permission to share the following two accounts:
‘Lizzy’
I have complex PTSD and DID as well as depression and anxiety. As a result of my childhood, I experience significant dissociation and fragmentation, and have a lot of issues with forming attachments or trusting people. I don't let anyone near me, nor do any of my other parts, or at least we didn't until we met my first therapist. I am terrified that people will abandon me or hate me; not that I can ever blame them. My experience of myself is that I am vile, worthless and evil.
This was with my first therapist who I had been seeing for a year. I went in for a session one day for her to tell me at the end of the session that she would be taking the next two months off to have a break and I wouldn't see her for 9 weeks. She made it clear that no contact would be allowed during this time .I asked if there was a colleague she could refer me to just for the period that she would be away as she knew I was going through a particularly difficult time and she said if I wanted to see someone else I'd have to sort it myself. I loyally waited out the 9 weeks before seeing her again. At this point I was in crisis; I was suicidal and had already made one failed attempt, unable to function very well at all and struggled to meet even my most basic needs. I was entirely alone, and my trust in her had been broken by such an abrupt and pro-longed break.
When she returned to work I dutifully attended my appointment and she apologised for taking time off so suddenly. She asked how it had made me feel and I told her that I'd felt hurt and abandoned; essentially uncared for. I told her I couldn't trust her and was afraid she would leave me again. She promised me that she would not take more time off work, that she wouldn't be going anywhere and that I could trust her and she'd never leave me. She said she would never hurt or reject me and that she'd always be there for me. Rather naively, I believed her. I was extremely vulnerable at this point and when she encouraged me to open up and trust her with my most closely guarded experiences, I did so, sharing information that I'd never considered sharing before.
This went on for a month; me sharing my deepest secrets and her pushing me to trust her, to give her more of myself. And then on the day of my 5th appointment after her return she phoned me and terminated. She said she needed time away from therapy and not to contact her. She promised to contact me when she came back so we could have a termination session. I found out about a year later that I had been her only client who she terminated over the phone, everyone else got termination sessions, and that she was indeed back practicing but had never bothered to tell me or give me the chance to say goodbye. Just like everyone else in my life, she had turned her back on me when I needed her most, and treated me with less care than her other clients. She had always said that I meant the most to her, but clearly when it came down to it, I meant nothing. A year of therapy ended with a 2 minute phone call and all of my fears of being worthless and my fear of abandonment came true
‘Sofia’
I have a complex trauma history and a dissociative disorder. In my journey through the therapy world I have been hurt and re-traumatised by well-meaning therapists who have underestimated the level of hard work and determination and commitment it takes to work with a client who has complex trauma. Some of the most re-traumatising experiences have been at the hands of intelligent, experienced and competent therapists who simply got lost and overwhelmed in the process.
'The pain of the abandonment pattern recurring was acute, terrifying, desperately retraumatising and had me convinced that no one could help me'
Twice I was terminated abruptly by two separate therapists whom I’d developed a strong bond with and the abandonment echoed the original abandonment of my mother who left me when I was a child. The pain of the abandonment pattern recurring was acute, terrifying, desperately retraumatising and had me convinced that no one could help me, that I was worthless and I was doomed to be abandoned repeatedly every time I reached out for support. I felt like I was too complex, too much like hard work, too much of a burden, too disruptive, too demanding, too broken. After each abandonment, I felt suicidal and was plunged into a deeply dissociated trauma response.
The thing that was most traumatising for me was the way the terminations were handled. It felt like the therapists just wanted to get rid of me as quickly as possible. Therapists who had spent over a year trying to gain my trust, cultivating an attachment, convincing me that they weren’t going to leave me or abandon me, that they were a safe base, did exactly that. Twice it came out of the blue, (albeit during a tumultuous period of my attachment process ) and twice it felt to me like there was no discussion about it, very little processing time with the therapist and very little willingness to answer my questions about what had happened, there was no time or help in finding me a more suitable therapist, there was no hand-over period. It felt like I was ousted from the therapy relationship with very little say and very little care. They just washed their hands of me. I was left in a state of shock, stunned and heartbroken and in disbelief that this person who claimed that they cared about me, could just disappear like that, knowing that it directly fed into my neglect and abandonment history.
I asked around to see if any therapists had any experience of having to end abruptly with trauma clients and received the following response:
‘I'm having to end abruptly with a handful of trauma clients due to a cancer diagnosis. The cancer I have is a chronic cancer that will permit me to return to work, but very immunocompromised. I know I won't be able to give them the consistency they deserve. And in fact- have had to deal with their rage and grief and the way my cancer triggered them through the thick of my cancer treatment (them leaving emails, phone messages).
It was a load I could carry when I was well- but now that I'm diagnosed and my life changed - I've suddenly "dropped the baby" - which was very difficult and I felt great conflict about. Of course I provided referrals - but they feel rejected anyway. Feel that they are "too much" and have a hard time seeing past their trauma to accept that my capacities have changed. It's been very sad.’
We can see here that even when the therapist was able to articulate why she was having to take a break from therapy and that referring on was in everybody’s best interests, it was still clearly very difficult for her clients. I don’t think that there are any easy answers here but I thought it important to consider this angle too. Sometimes it really isn’t possible to carry on working with clients who need long term ongoing contact and support. But regardless of the reason why the therapist ends there is an emotional consequence for the client.
A personal experience
Several years ago I had an experience of a therapist having to discontinue work with me due to a professional conflict of interests. Although as a qualified counsellor I completely understood and accepted why he had to terminate the work, I was devastated. This was substantially softened by us having an ending session where we could round up the work and say goodbye. I can understand that to have been suddenly dropped by a therapist with no chance to process or understand what had happened or why, would have been much more upsetting and possibly affected my ability to trust another therapist.
What I have learned from my personal experience as well as my own client work and listening to people such as Lizzy and Sofia above, is that wherever possible a termination should not be abrupt. Referral to other suitable therapists or specialist services (for example via the GP) and where possible having a handover period will help mitigate some of the emotional impact on our clients.
Finally, here are some helpful words for therapists from Carolyn Spring from her article Ten Steps to Becoming a Dissociation friendly Therapist. Carolyn is a director of Positive Outcomes for Dissociative Survivors (PODS) who offer nationwide training in working with trauma. I highly recommend her training to fill in the gaps in trauma work left by standard therapy training.
‘Flexing the boundaries is a good thing as long as it’s not a reactive thing, as long as it’s a decision that you’ve reflected on and you’re comfortable with and you can maintain it and not offer it and then retract it: we know of too many people with dissociative identity disorder whose therapists have given ‘too much,’ only to realise months down the line that they can’t cope with what they are giving. To escape from their promises, they then quit altogether – please don’t do that. Flexing the boundaries is a good thing if it’s truly in the client’s best interests and it’s not just there because you can’t hold the anxiety of how we are between sessions. Flexing the boundaries is a good thing if it’s a mindful act that comes from a deep-and-wide assessment of the plan for therapy that you have co-created with the client, and it’s not a buckling to the pressure of a traumatic attachment need or a fight-or-flight response.
'Working with trauma is traumatic'
Above all, hold the boundary of your self and don’t become enmeshed and try to rescue. In order to heal from boundary violations, most of all we need you to avoid replicating the dynamics of intimate invasion we encountered in childhood. We need you to remain you, and for us to be allowed to become us.
A burnt-out therapist is a dangerous thing. Working with trauma is traumatic: secondary, or vicarious, trauma is a very real phenomenon and bearing witness week in, week out, sitting with us, week in, week out, empathising and attuning your right brain to our assaulted minds, week in, week out, will have an impact on you. You need to get a life. You need to look after yourself, and not feel guilty for doing so. Our lives exist on a drip-feed of trauma in every waking and every sleeping moment: we can’t escape it. We are coming to therapy because we don’t want it to be like this anymore. So we need a signpost to a better life, and we need to know that you’re living it first. I don’t ever want to do flower arranging (the thought!) but I am glad my therapist does, because it reminds me that there is beauty and peace and creativity in the world and there are places and spaces and moments when trauma doesn’t reign. It reminds me of what is possible, even when I am feeling that everything is impossible. So have your holidays and your days off and your days out, and replenish your energies and keep coming back refreshed so that you still want to work with us, rather than feeling that you should. Get a life, and enjoy it, because that’s what we want to be able to do too.’
I return to my original point which is that I do not currently believe that there is adequate training in trauma awareness amongst professionals. I am conducting some research and plan to question the professional bodies on their stance on whether or not it should be a part of basic therapy training. In the meantime, I urge all therapists who haven’t already done so to equip themselves accordingly and seek out appropriate CPD.
If you are a client looking to work on your own trauma with a therapist then please ask any potential therapists what training they have in this area. Sadly, it does not go to follow that if they are qualified then they will know how to work safely with trauma. There are however some wonderful therapists who are aware of the issues described and who do some great work. PODS holds a register of therapists who have completed some of their trauma training which would be a good starting point.
With many kind thanks to those that contributed to this article. Both Lizzy and Sofia were happy to contribute to an article raising awareness of these issues.
Suggestions for continuing professional development:
Books:
Training:
Authors Bio
Amanda Williamson is an accredited member of the BACP and works in private practice in Exeter, Devon with individuals and couples. Along with founder Phil Dore she is part of Unsafe Spaces who campaign for the regulation of counselling and psychotherapy in the UK. Through being vocal about the lack of statutory regulation and abuse in therapy, some of her work is with clients who are recovering from abusive experiences with therapists. You can connect with Amanda for updates and further information via Facebook or Twitter
