THE THERAPEUTIC RELATIONSHIP: THE ESSENCE OF TRAUMA TREATMENT
The information contained in the previous chapters provides a framework for understanding the nature of trauma. This chapter continues with attention to the therapeutic relationship, which provides the holding environment, or a container for the work, and a treatment matrix. Within this matrix, traumatized individuals are able to move from living in the “never-never land” of past trauma to living in present time, having a sound sense of self and the ability to live with hope, joy, and good relationships. The paramount value when engaging in the assessment and treatment of trauma survivors is stated in the first Approaching Treatment The adage “knowledge binds anxiety” is true for both the client and the clinician. Clinicians need knowledge concerning trauma and its effects to be able to work both effectively and ethically with survivors. In addition, clinicians need to be able to share their knowledge about trauma’s effects on an individual in an appropriate and timely fashion with clients so that the clients can understand the reasons behind their distress and have a roadmap for moving out of it. After sharing information with clients about various aspects of trauma, such as how the brain works, how symptoms develop, why those symptoms are no longer adaptive as they once were, and how to reorganize psychoneurobiological responses, practitioners may see clients returning the following week and expressing a change in their view of the situation. A client might say, “I was so relieved to understand what was happening to me. It took the mystery and some of the fear out of it. To be able to say ‘Oh, that’s why . . .’ was such a relief, even if I still had the anxiety attacks or phobias or sadness.” Clients also respond with statements like “I hadn’t put that together before. I never made the connection. It never occurred to me that the things that happened so far in my past could still be affecting me today.” Clinicians will sometimes fail to share information with their clients that might benefit them. An important part of clinical work is offering a psychoeducational approach to demystify the terrifying array of symptoms and distress that clients frequently experience. Timing of such interventions is, as always, important. Clinicians need to attend to the client’s readiness to hear certain information and to the client’s ability to hold and integrate the concept that past trauma can affect the present as a useful and empowering piece of information, rather than as information that engenders more hopelessness or futility. The clinician needs to be aware of the timing and pacing of their interventions as well as of body language, tone of voice, and eye contact with the client. Proximity (how close or far away the clinician is sitting from the client) is also a factor in how the messages are delivered and how they are received. The Roots of Traumatic Transference At one level, all traumas are relational traumas. By definition, most private trauma is perpetrated by other individuals. Even during medical interventions, when the intention of the contact is to heal, the medical staff and the pain from the procedures can become entwined in a person’s mind. Relationships frequently can become a minefield following long-term traumatic exposure. When family members or other persons with authority and power perpetrate abuse on children, particularly when the abuse takes place over a significant period of time, all subsequent relationships become tainted with the residues of betrayal, mistrust, fear, and shame (van der Kolk, 2014). Commonly, complicated relationships with power, control, and authority may result. The child, and later the adult, learns to see the world through a “trauma lens,” rather than as it really is. The transference becomes a “traumatic transference.” Pearlman and Saakvitne (1995) speak of the “trauma triangle” that comprises the lens of vision for survivors. As shown in Figure 7-1, all relationships are then viewed as involving some combination of three roles: Victim, perpetrator, and nonprotecting bystander.
general principle of the APA Ethics Code (2017b), “psychologists strive to benefit those with whom they work and take care to do no harm (2017b).” The first priority is to make certain that a clinician's intervention choices, actions during a session, wording and tone of voice, and overall manner of engagement do not cause undue distress for the client. Given the sometimes-fragile nature of individuals who have experienced trauma, clinicians need to have a sound understanding of the nature of trauma and trauma response. Two other concepts that inform the arenas of the timing and pacing of therapeutic interventions are titration and pendulation. Titration refers to the concept of dosing, as in the optimum dosage of a medication to be taken. Here, it refers to addressing the optimum dose of traumatic memory or material that the client can contain and manage at any given time while staying within the window of tolerance and not becoming dysregulated (neither abreacting nor shutting down in response to the material). Pendulation refers to the back-and-forth swinging motion of a pendulum. During trauma treatment, the clinician helps the client to move back and forth from more distressing material to less distressing material, spending time addressing the actual traumatic events or symptoms and then moving gently into neutral or strength-based areas of the client’s functioning. Again, the goal is to have the client remain within the window of tolerance so that they do not become retraumatized by an overzealous treatment approach. It is important not to err on the side of full disclosure too quickly, without attention to the client’s ability to tolerate the revisiting of painful material in a safe and contained manner (Herman, 1992). No benefit is gained by additional suffering for the sake of information retrieval. The clinician’s attention to the client’s fear, pain, hurt, anger, grief, and other negative states is counterbalanced with support for and acknowledgment of the client’s positive connections, accomplishments and successes, humor, and other strengths. If light-heartedness is a component of the treatment session, at the very least the client has experienced a break from their distress and made the neurobiological changes that go along with feelings of love and happiness. Careful attention to the client’s ability to receive and process positive feedback or support, so that the person does not feel dismissed or made light of, is as important as attention to the traumatic arenas. This approach respects the client’s window of affect tolerance by monitoring their ability to process difficult material and balancing the session and the course of treatment with all aspects of the individual, not only the hurt and wounded parts.
Figure 7-1. Trauma Lens Triangle
Note: From Western, © 2018. The survivor views themselves in every relationship as being a victim or having the immediate potential to become a victim; as not protecting, when they should have (bystander); or as a perpetrator. The survivor also views the other person through the same lens. Learning to see and participate in relationships without this distorted lens, but through authentic and empathic connections, is one of the main goals of the therapeutic relationship.
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