Conclusion The therapeutic relationship is the heart and soul of the treatment matrix. All other techniques, interventions, methods, and theoretical perspectives take place within the context of this healing relationship. Careful attention to the potential for the roller-coaster ride of this relationship and a willingness on the part of the clinician to remain in connection throughout are crucial. The ability to be truly present to bear witness and share in the process of healing are paramount for good trauma treatment. In many ways, this approach parallels good treatment for any population, but extra attention needs to be paid to the power dynamics, issues of trust, and clients’ heightened sensitivities because of the trauma lens through
which they tend to view the world if the trauma has been chronic in nature. Attention to potential triggers within the therapeutic session and the flexibility to be able to tailor the session to the individual needs of clients will make this a safe place in which to do dysregulation work. Balancing a warm, empathic approach with impeccable professional boundaries will avert the experience of boundary violations on the part of clients in this intimate relationship. A history of disorganized attachment can be countered by the experience of healthy attachment in the therapeutic dyad, and the mutuality and relational nature of the bond will allow the survivor to feel felt and truly seen and heard.
Table 7. The Therapeutic Relationship with Trauma Survivors: Qualities Needed by the Therapist ● Impeccable boundaries The clinician should take care to maintain and respect physical space boundaries, provide clarity about reasonable and viable clinician availability, not share personal information gratuitously, and start and end sessions on time. ● Human warmth and emotional honesty The clinician should present themselves in a warm, engaged, connective way as opposed to the “tabula rasa” (blank slate) approach of traditional psychotherapy. They should be willing and able to share with the client when they have felt emotionally moved by the client to counter the learned historical message that what the client does or says does not matter. ● Consistency The clinician should aim to maintain their own equilibrium in the face of client distress, adhere to ethical and therapeutic boundaries, and have a regularly scheduled meeting time when feasible. ● Careful balance between professional distance and empathic attunement The clinician should maintain empathic connectedness without “spilling” personal information or history of personal experiences. ● The ability not to personalize the transference or the testing The clinician should recognize that some transference is inevitable and should not take it personally, whether it is idealizing or demonizing. The clinician should remain aware and mindful that it is common for trauma survivors to enter the therapeutic relationship with mistrust and wariness and that vicissitudes are normal. ● Appreciation of the intricacies of the power dynamics The clinician should recognize the inherent power differential between clinician and client and make every effort to reduce the hierarchy so that the power dynamics become “power with” rather than “power over.” Awareness that previous caregivers may have misused their power is also critical and should be addressed directly. ● Ability to bear witness to atrocities The clinician should be able to stay centered, grounded, and present while hearing about detailed traumatic events and have strong outside resources of their own for debriefing as needed. ● Ability to be there for the “long haul” The clinician should recognize that trauma treatment can take a long time and, as much as possible, work with survivors until their need for treatment is completed. It is the consistency over long periods of time that can rebuild shattered belief systems and heal relational betrayals. The clinician needs to be clear and honest from the outset if the treatment will be constrained by outside factors and plan for a smooth transference or organization of environmental resources. ● Ability to withstand strong emotions The clinician needs to be prepared to hold and tolerate the expression of many emotional states, including rage, panic, terror, deep grief, disgust, shame, hatred, and others, some of which may, at times, be directed toward the clinician. ● A good sense of humor A sense of humor will “inoculate” the clinician against taking in toxic emotional states as well as provide a balance to both client and clinician to the frequently distressing material. Laughter can be therapeutic, and shared laughter creates connection. ● Flexibility The clinician should balance flexibility with consistency. In other words, the clinician should know “when to hold and when to fold.” The clinician needs to be willing and able to think outside of the box for creative solutions. Adjusting the physical space, including seating or lighting, as well as the style of work or methods used in response to the client’s expressed needs around safety and comfort, is respectful and empowering to the client. For example, the clinician should be willing to sit on the floor rather than in chairs, open or close window shades to accommodate anxiety, or even sit back-to-back for part of the session so that the client will not experience feeling shamed while recounting a particularly difficult part of the trauma. ● A moral rather than a neutral stance The clinician needs to be able to address the client’s perceptions of good and evil in the world and be willing and able to take a stand on the client’s behalf when needed. For example, the clinician should be able to say to a client, “That was wrong. It never should have happened to you; it was not your fault.” ● Good resources/sources for personal renewal The clinician needs to have good support systems for professional and personal support, learning, self-care, fun, and leisure. ● A working spiritual perspective The clinician needs to have a way of making meaning for themselves in the world and a traditional or nontraditional place for meditation, prayer, or contemplation. This place can be in nature, in a house of worship, or in a private space. The clinician should have knowledge of their own belief systems to sustain the soul and the psyche, in the face of bearing witness to pain and suffering. Note : Adapted from Schiller, L. (2008, July). Getting unstuck: Using dreamwork to heal traumatic memory. Paper presented at the International Association for the Study of Dreams Conference, Montréal, Canada.
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