Treating Trauma Survivors
Lynette Danylchuk, Ph.D.
This article is not meant to replace therapy by a licensed professional. Each individual is unique, and cases and situations vary. Permission is granted to print for personal use only. All publication rights reserved by the author.
The way in which the therapist perceives the client coming for counseling is one of the most powerful elements of the therapeutic process. It is very easy, and very common, for therapists working with abuse survivors for the therapist to fall into a traditional medical model, doctor-patient kind of relationship. In this kind of relationship, the doctor is well, the patient is "sick," and the doctor assumes a position of power over the patient, telling the patient what he or she needs to do to get well. Unfortunately, this type of unequal power relationship in therapy - even though it is based on an attempt to honestly help the client - can undermine an abuse survivor's healing by duplicating dynamics that were part of the original abuse. In the original abuse, the abuser was in a position of power over the survivor. The abuser used the position of power to disempower the victim - the weaker, the more humiliated and disempowered the victim, the better the perpetrator would feel. Victims of abuse have been systematically stripped of their own autonomous power - they feel powerless, perceive themselves as powerless, and can often only feel power in the context of destructive behavior. Survivors have had to learn to be outer-directed - to pick up on what is expected of them and to respond accordingly. In the therapy setting, a therapist who assumes a role of hierarchical power in relationship to the client helps to keep the client in a one-down, subservient, powerless position.
This is not to say that the therapist does not or should not have any power or authority. It is not power itself, but the nature and expression of the power that is important. There are two types of power or authority - irrational or hierarchical, based on status, and rational, based on expertise. The kind of power or position of authority that is used to disempower survivors is irrational and hierarchical. The kind of power and authority that needs to be modeled and taught in the therapeutic relationship is rational. Erich Fromm said it well in his book, To Have or To Be, "Rational authority is based on competence and it helps the person who leans on it to grow. Irrational authority is based on power and serves to exploit the person subjected to it." The power used by the therapist needs to be an expression of his or her expertise, knowledge, training, and sensitivity. In this context, the client can also begin to feel his or her own authority and begin to develop a healthy feeling of appropriate power.
The commonly used word for this is "empowerment". How do you empower a client? The first step is to set up the therapeutic relationship to include the client. That means that the therapist sees himself or herself as a kind of facilitator or coach. The analogy of being a coach includes the reality that it is the client, like the athlete, who is doing the majority of the hard work. In the case of psychotherapeutic process, it is the client who carries the memories, feelings, and wounds from what happened in the past. The therapist, like the coach, gives feedback, offers a different perspective, can point out feelings and behaviors that need to be worked on, and can be supportive. The therapist, however, like the coach, goes home at night and does other things; while the client, like the athlete, has to continue to care for the body, mind, and spirit, and tend his or her injuries.
There needs to be more of a feeling of equality in the therapeutic relationship than is usually found. Both people, therapist and client, are alike in their common humanity. They are not innately different. The abuse survivor is not a defective human being. The abuse survivor is a normal human being suffering from the effects of an horrendous experience, and sometimes from the effects of an environment so dysfunctional that it is like its own subculture. An abuse survivor is a person with a mild to catastrophic case of Post-Traumatic Stress Syndrome. There is nothing 'wrong' with the survivor, just an extreme amount of trauma along with the normal consequences of trauma. There is both enormous strength and fragility in the survivor. The abuse survivor is, in a way, like a survivor of Auschwitz - the ones who survived were the strong and the lucky, but when released, they were extremely fragile and took a long time to heal.
The PTSD of abuse survivor is similar to the PTSD from other traumas in that it tends to be cyclical in nature, with periods of intrusive thoughts and feelings followed by avoidant thought and behaviors. That means that a person who has experienced a traumatic event will have times when he or she cannot get the experience out of consciousness, and times when the awareness of the experience is conspicuously absent. Typical things people say in the intrusive stage are, for example, "I can't stop thinking about it"; "I can't stop feeling about it"; and "I'm having nightmares about it." Hallucinations are another form of intrusive images found in some abuse survivors - they are sometimes literal memories, and sometimes symbolic. In the avoidant stage, a person may say. "I tried not to think about it"; "it doesn't seem real"; and, "My feelings about it are numb." These are common, normal parts of PTSD.
The person with PTSD needs to know, "What could I have done differently?" (Figley) If you've had any kind of traumatic experience in your life, from severe abuse to being in a natural disaster such as a flood or an earthquake, than you, too have had some experience of PTSD. If you had as much traumatic experience at as early an age as some abuse survivors, then you would be feeling and behaving in a very similar way. We are all human, and we will all react to stress - the more stress, the more reaction: the younger the age of the person and the more severe the stress, the greater the effect. According to studies, the nature and intensity of the stressor is the most significant factor in determining the person's stress reaction (Green, Lidy, & Grace, l985).
One of the most important things you as a therapist can do for a survivor, is to treat the survivor with all the respect due to another human being like yourself, and normalize their symptoms . Please take not of my emphasis on the word normalize . Any human being subjected to catastrophic trauma will react symptomatically. The symptoms you see are the consequence of the abuse the client has suffered, and those symptoms can also serve as signposts to the nature and extent of the abuse. If you look at the symptoms as a consequence of the abuse, then you can ask, "What kind of abuse would cause this kind of symptom?"
The answer to that question helps you, as the therapist, to look at the client's symptoms in such a way that you are able to help the client work through them. Look at all symptoms as potential attempts to communicate. I say potential, because not all symptoms are forms of communication; some are primarily physical and need to be treated as such. It is important to listen to the client, and not assume that because some symptoms are psychological in origin, they all are. Symptoms may be either psychological or physical, or both psychological and physical. Ideally, you as a therapist, are a part of a treatment team, including a physician, a psychiatrist, and a group of support people including, hopefully, someone living with the survivor.
When you look at physical symptoms, the first step is to check for physical basis. The next step is to talk with the client about what the symptom might be trying to express. It is important here to work with the client, and not assume your ideas are automatically right. For example, a client may be in a lot of physical pain with no apparent physiological source: ask the client if the pain is familiar. If so, when has she or he felt it before? Start to look for patterns in the pain - does the person often feel this pain at the same time of year, around certain family members, when dealing with the same memory? Another way to start to deal with a symptom of pain is to have the client feel the pain as intensely as possible, and let the pain 'tell' the person what message it carries. Typically, the therapist can use phrases such as "go with the pain, let it be there, let it intensify." This sometimes leads to a memory, or sometimes allows expression of repressed or suppressed feelings. Pain in for form of headaches is common, and is most often associated with inner conflicts and suppression of feelings, usually anger. Frequently, headaches will disappear if anger is expressed. [Gestalt work]
Symptoms are often like windows into what is going on within a person. Pain is one frequent symptom. Acting out is another. Acting out includes behavior such as self-mutilation, overt hostile aggression, and abuse of sex, drugs, or alcohol. If you have a client who is acting out, it is important to discover what the person is acting out. It is not helpful to blame the client for destructive behavior; in most cases they are already suffering from it. It is far more helpful to work with the person to discover what the healthy intent behind the symptom was, and how that intent could be expressed constructively instead of destructively. [Growth model, Virginia Satir] Quite often the client's feelings that are being expressed in acting out are pain and rage. Also, the client may be reenacting an unresolved traumatic experience in an attempt to resolve it, or to gain control, either in a rather obvious way such as provoking a fight or reenacting physical abuse, or in a more abstract or complex way, such as cutting the body.
Self-mutilation can be a symptom with many aspects. Some people cut themselves because they h to see if they're still alive. Others have cut themselves to get in touch, and to distract themselves from their emotional pain by creating physical pain. Sometimes the cutting is an attempt to stay in crisis mode to protect the self from memories and feelings. Other times cutting is a form of self-hatred associated with the client feeling responsible for being too little or too helpless to stop the abuse. Many clients hate their bodies for feeling so much pain, and hats themselves for any stimulation their bodies felt during their abuse. If the client can learn what she or he is trying to express through cutting, then an option emerges and the client begins to have a choice in her or his behavior.
Once you and the client have an idea of what is trying to be expressed, then you need to teach another constructive way in which to express it. This is a cooperative venture - talk with the client, get feedback, brainstorm with the client; there is no set way to do things, each person is different.
Symptoms and acting out are ways in which the client stays in touch with memories and feelings without consciously being aware of them. The symptoms and acting out serve a purpose - they are the mind's way of saying, "I shall return." They point to what happened to the person, so that the person will be able to reconnect and heal. If the therapist can see the inherent healthy purpose behind the symptom and help the client to connect to that, then the need for the symptom will eventually diminish. This approach also helps the client see herself or himself in a better light, as a human being who is trying to connect and whose symptoms mean something. Clients are aware that their symptomatic behavior is not acceptable to society, and they take on the negative labels people put on them, which then, sometimes reinforces the negative behavior. Seeing themselves as bad or unacceptable only reinforces the feelings they had from their abuse. If the therapist can look beyond the symptom and help the client see that the mind is holding onto feelings and memories through symptoms and acting out so that the client can one day heal, the client's self image can improve and she or he can begin to work toward that healing.
Symptoms and acting out are ways to express what was inexpressible. To heal, the client needs to learn to express indirectly and constructively. A common element in abuse is the provoking of extreme feelings and reactions, followed by punishing the person for expressing those feelings. Eventually, the person learns to block feeling, numb out, and split off in some way to survive. An important part of healing is identifying the feelings, connecting them with their origin in the past, and expressing what in the past could not be expressed.
Often, the feelings will surface masked by present circumstances in an intense response to a current situation - in a projection or transference. The client needs to learn to recognize this pattern as a normal human dynamic (as opposed to a symptom of pathology), so that they are willing and able to seek the more threatening association under the immediate response, which are being defended against by the projection. Sharing this therapeutic dynamic with the client reinforces the egalitarian power relationship that allows him or her to choose, with the aid of your facilitation and support, to process the feelings within the context of the memory. For abuse survivors, this means expressing terror, grief, rage, abandonment, and pain, both physical and emotional. These feelings are as intense as was the horror of the memory. The respectful partnership you have established will greatly ease the confusion between past and present, and will help the survivor differentiate between the initial superficial resemblance of perpetrator and therapist, when the memory surfaces into consciousness.
If possible, it works most effectively to help the client gradually be able to concentrate on one memory at a time. It is a common pattern, however, while working on one memory (thereby encountering increased resistance to that memory), to have anther memory - which is not being defended against - emerge more fully. Then, as that memory is processed, increased resistance to it will allow the previous memory to re-emerge.
Help the survivor see the reality of the over-powered and set-up reality of the abuse situation. After Gestalt work, go back and talk about what happened, teach the client self-soothing techniques so he or she can do what wasn't done - validate and comfort. Non-sexual, comforting touch is okay and often essential for healing, but this is something that must be discussed and negotiated with the survivor.
Some mistakes to watch out for are: thinking that accessing the memory is enough; using hypnosis to take control away from the client; becoming enmeshed in the client's system or the perpetrator's thought control system; trying to rescue the client; not incorporating significant others in the process.
The feelings, the symptoms, the acting out behavior will all make sense once a person has connected them with their origin. Survivors often feel "crazy". It is helpful to let them know that they are not crazy, "crazy" is a word used when you don't understand what is going on; once you understand, the feelings and behavior no longer look crazy, they make sense. Making sense does not mean that the behavior is okay, but it does create a starting point to direct the behavior in a more constructive way. How do you do that?
As much as possible, try to provide a context in which the client can express feelings in a natural way. Sadness is naturally expressed through crying, terror often comes out as screaming, rage comes out as loud yelling and physical aggression. In the original abuse, the natural expression of feelings is usually blocked. A person being abused is often threatened or punished for expressing their natural feelings, and they learn to block those feelings in some way. It is a necessary part of healing to reconnect with the natural expression of feeling. In the beginning, words are seldom adequate to express feelings as intense as those provoked by abuse. Abuse clients need the opportunity to express their feelings to heal, and that means being provided with an environment in which it is safe to do that. They need to be able to scream, sob, and cry out; to feel the pain they've kept trapped inside; to release it and then move beyond it, learning healthier ways to care for the self and relate to others.
The intensity of the natural reaction to abuse dictates a different kind of therapy environment to allow sufficient emotional expression to enable the client to work feeling through to the point where words can be used. That means that it is difficult to work effectively at this level with abuse survivors in an office where people need to be quiet or where a release of anger could hurt either people or property. There is a double message communicated by the therapist who says, "express your anger" in as office decorated with delicate collectibles. There is also a double message communicated by a therapist who tells the client to express his or her intense feelings, but is not really able to deal with them. The client will sense that the therapist can't handle it, and will protect the therapist by holding back information and feelings.
There is a strong inclination in survivors to be "good clients". Abuse trains people to be outer oriented, to take their cues from the people around them. Survivors are often very sensitive to emotional cues from therapists, and will modify their behavior accordingly. This is not always done consciously, and is quite often unconscious, so that the client may feel guilty for not being about to follow the advise or direction of the therapist without realizing that he or she is picking up the therapist's resistance to dealing with an intense feeling or memory.
The survivor initially has little or no reference for benign motivation. If the survivor is invited to express questions, criticism or doubts about your abilities, environment, approach or motives, and has learned that you will respond honestly and thoughtfully, taking his or her concerns and perceptions into serious consideration, the potential for growth is enormous. It is possible to reach a consensus with the survivor about the actual sources of resistance. When resistances are appropriately identified and agreed upon, a strategy can be jointly formulated to overcome the resistance. This may involve a change of environment, utilization of a treatment team or adjunct facility, a different therapeutic approach, agreements about joint definitions of words or phrases, or a decision to shift the emphasis of the current therapeutic process.
When I talk with therapists dealing with survivors, I quite often hear them express concern about having clients exhibit intense feelings or recall horrendous experiences, fearing that the client will not be able to handle the intensity. It is important to look at how each person, client and therapist, will be able to deal with the memories and feelings. The client will need to have sufficient time to process feelings, so she or he will not have to walk out of the therapy office feeling disoriented and emotionally raw. In working with abuse survivors who are recalling and processing their abuse, the standard 50-minute hour is often inadequate. Double sessions tend to work better, allowing more time to express intense feelings and move a little beyond them.
Consider also the situation into which the client returns - is there support available at home or from friends? It may be necessary, at times, to discourage working on a powerful memory or feeling because of lack of support outside therapy, or because the client will have to function in a way that will be impossible if powerful memories or feelings are being processed. For example, if you know that client is being driven home by a supportive, understanding person and will be well cared for, then take the opportunity to process as much as possible. On the other hand, if the client lives alone, or is solely responsible for the care of small children and does not have help or support, then it would be necessary to move as slowly as possible with memory and feeling work until a supportive context can be built. It is not always possible to do this. Sometimes you will be confronted with a person who has no support and who has responsibilities, who is also having flashbacks. In this case, it is necessary to process feelings and memories while seeking to built a support system that will see the person through the crisis. This type of situation is one in which medication can provide an appropriate, albeit temporary, slowing of the process [Therapy techniques: Brief, Gestalt, Michael White - Narrative, Psychodynamic, Family Systems, Cognitive.] Check with the client to evaluate what has been helpful and what has not].
Have the client make a list of phone numbers to call for support: crisis lines, friends, numbers where you might be reached. It can also help to have a list of how to cope with the feelings and flashbacks. Sometimes all a person can do is recognize he or she is having a flashback, and sit down holding onto the sides of a chair until it is over. Any kind of plan that the client can see might work needs to be written down by the client and placed where it can be used quickly. It often helps to draw the flashback, write it out, hug a pillow or stuffed animal, and be as self-comforting as possible. Ideally, flashbacks and memories will come up in a therapeutic setting where they can be expressed, and understood, and where a plan for continuing work can be set up. Remember, clients would also prefer for their memories or flashbacks to occur in therapy and end at the end of the session. Inability to control memories or flashbacks is not being uncooperative.
Hopefully, throughout therapy, the therapist is sharing knowledge in such a way that the clients eventually can be their own therapists. If therapists do their job well, they will work themselves out of a job with each client, and the client will fell equal to the rest of the adult population. This is, again, a reflection of a power structure built on expertise, not hierarchy.
Finally, how do you take care of yourself while working with abuse survivors? It is common for therapists when working with people with severe PTSD to suffer from secondary PTSD. You may begin to have nightmares, and other symptoms of PTSD. It is essential that you take care of yourself. Part of that will be letting the client know that you, by yourself, are not adequate to meet all his or her needs; that the client will need more help than just you can give. Don't take on the whole load. Also, be sure to find ways to renew yourself. Stay in touch with the beauty of life. Exercise, meditation, socializing, taking walks, having dinner out, movies, books, and other things that give to you, need to be part of your regular schedule. Set limits with clients. Have someone you can talk to. If possible, have your own therapist, or create a support group for therapists dealing with abuse. Think about what makes you smile. Are you giving yourself enough time to incorporate that in your life? Remember why you are doing this - is feels great to know that someone whose life was once unbearable can heal. Know that whatever you to help counts. All of us, therapist and client working together, will make a difference.
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Copyright © 1992 Lynette Danylchuk PhD, published in Survivorship , May 1992
Copyright © 2007 Lynette Danylchuk PhD