A NEW BOOK FOR TRAUMA THERAPISTS
Trauma and the Therapist by Laurie Anne Pearlman and Karen W. Saakvitne.
W. W. Norton & Company, Inc., 500 Fifth Avenue, New York, NY 10110. Publication Date 1995. xxii + 451 pages, ISBN 0-393-70183-2. Price $40. 00 (USA), $50. 00 (Canada)
Trauma and the therapist is a book devoted to psychotherapy of trauma victims and especially concentrates on adult survivors of childhood sexual abuse and incest. To put this book in perspective it is essential to know firstly that the book brings out the importance of both, the therapist and the patient and their mutual impact on each other. In this respect the book deviates from the usual medical literature, which when talking about trauma therapy, usually focuses on the client. Secondly, they focus and highlight extensively on two important components of therapy - countertransference [The therapist's response to the client] and vicarious traumatization [the therapist's response to the stories of abuse told by client after client].
While talking about trauma therapy the book almost exclusively focuses on adult survivors of childhood sexual abuse and incest. Few victims of childhood sexual abuse enter adulthood without some symptom of the crime perpetrated against them as children. Incest scars virtually all facets of a victim's life and has important emotional, social and physical consequences. The inability to trust and avoidance of both intimacy and emotional bonding make them difficult, yet challenging patients to treat.
It is interesting to note the reasons given by the authors for the special focus:
1. Strikingly high prevalence of childhood sexual abuse in the general population.
2. They are often challenging psychotherapy clients.
3. For this population this therapeutic relationship is the central process of healing and at the same time enormously threatening.
4. Countertransference and vicarious traumatization issues are particularly complicated and difficult.
5. The percentage of therapists who are themselves survivors of childhood sexual abuse is higher than the percentage of survivors in the general population.
The book is arranged into five parts:
The first part is divided into three chapters [Chapters 1, 2 and 3] and basically deals with theoretical underpinnings of the book. There is an authoritative description of the basic issues related to trauma therapy and a reader will do well to acquaint himself thoroughly with the information provided here as it sets the tone for the rest of the book.
The first chapter discusses therapeutic relationship as the context for countertransference and vicarious traumatization. For trauma victims, the therapeutic relationship is the first step in the long and painful road to recovery. The focus on the therapeutic relationship, rather than a more limited focus on transference [that is the client], allows us to use countertransference as a fundamental tool of the work. As the authors write, countertransference can serve to make conscious that which is unconscious and bring dissociated effects into the room and relationship. Unrecognized and unanalyzed countertransference impedes our ability to be fully and actively present in the room with the client. Much importance is also given to the central role of dissociation in these clients.
The defense that ensured survival as a child now prevents the survivor from having an unencumbered adulthood. The authors also introduce the concept of vicarious traumatization in this chapter and emphasize that it has to be identified and addressed in a proper manner, otherwise it may have detrimental effects on the therapy.
The second chapter discusses the contributions and limitations of psychoanalytic theory to trauma treatment. The book acknowledges that basic tenets of trauma theory and therapy are based in psychoanalytic theory. The book also acknowledges specific limitations in the form of disinformation, theoretical authoritarianism, rejection of seduction theory, misuse of the concept of therapist neutrality, inaccessibility of psychoanalytic ideas and inattention to the therapist's personal meaning of trauma.
Chapter 3 describes Constructivist Self Development Theory [CSDT] - the book gives a very thorough account of this theory. It is described as an integrative developmental relational theory that forms a foundation for clinical work with survivors and the basis of conceptualization of the impact of trauma therapy upon the therapist. Constructivist self development theory, a unifying personality theory that integrates the clinical and psychological complexity of psychoanalytic theory with the clarity and contextual emphasis of social learning and other developmental cognitive theories. One underlying assumption in this theory is that individuals construct and construe their own realities, the clinical implication being that the meaning of the traumatic event is the survivor's experience of it. Hence each individual will bring a unique perspective on and experience of his own trauma and this has to be given due importance in therapy. A useful table showing the impact of the trauma on aspects of the self is reproduced here.
Each of the 9 chapters in part II addresses a specific countertransference issue that arises in intensive psychotherapy with incest survivors.
The authors have stressed time and again, the importance of countertransference in trauma survivors which can profoundly influence the development of therapeutic relationship. When used appropriately it can inform and enrich the treatment, if unacknowledged it can damage both client and therapist. The author's definition of countertransference includes both the response of the therapist to the client, his clinical material, transference and reenactments as well as the therapist's conscious and unconscious defenses against the affects, intrapsychic conflicts and associations aroused by the former.
Chapter 4 discusses the therapist's responses to the meaning of incest. The feelings elicited in the therapist may include horror, outrage and disgust and rage at the parents and society that allow such behaviors to occur. A particularly enlightening fact about countertransference to incest is brought forth when the authors point out that psychological literature reflects cycles of roughly thirty years in which child abuse is acknowledged and then ignored, a pattern that reflects the power of the wish not to know and the extraordinary difficulty of integrating the reality of childhood trauma into our own frame of reference. Another interesting response is the body centered countertransference. It is not unusual for the therapist to experience somatic symptoms that parallel the client's body experience. Hence countertransference responses are not only expressed through words and feelings as is usually assumed.
Chapter 5 addresses countertransference to transference paradigms that commonly emerge in psychotherapy with incest. Transference responses in therapy, as the authors point out, will be informed by and reflect the sequelae of childhood sexual trauma, including dissociative phenomenon, fluctuating ego states, severely disrupted beliefs about trust, safety, esteem, control, and intimacy, and disruptions in identity, world view and spirituality.
Chapter 6 discusses the therapist's response to dissociation, so commonly found in survivors of childhood sexual abuse. Chapter 7 discusses how countertransference influences therapeutic frame and boundaries. Countertransference influences both the establishment and maintenance of therapeutic frame. Many boundary negotiations hinge on assumptions about the role of client and therapist. These beliefs tap into identity issues, both professional and personal, for the therapist, and are thus susceptible to countertransference influences. The therapist's fantasies and affect inform countertransference responses to boundary issues. For example, when the therapist is angry at her client, she can wish to distance from her, to send her away, to hide behind rigid boundaries.
Chapters 8-12 discuss countertransference issues related to therapist's who are themselves survivors of incest, gender, therapeutic impasse, group therapy by co therapist and survivor clients who report abuse by previous therapist's respectively. Further elaboration by the authors informs us that the danger with survivor therapist's is that he may not hear what the client needs to say because of her conscious and unconscious preoccupation with her own needs. This unconscious myopia renders a therapist unable to see the client as a separate person with unique individual needs, and thus at risk for retraumatizing or reenacting early destructive interpersonal patterns with the client. Countertransference issues related to therapeutic impasse are important because the therapists own conflicts and defenses may blind her to the client's defensive process leading to a feeling of being stuck, unable to progress and move forward on the part of the therapist, client or both. Therapeutic impasse often challenges the identity and esteem of the therapist and constantly evokes strong countertransference response. The resolution of therapeutic impasse demands the most intuitive and creative work at a time when the therapist is feeling most ineffective and depleted. Yet the successful resolution of therapeutic impasse can be the nexus of a transformative experience for both the client and the therapist.
Part three is devoted to the tremendously important concept of vicarious traumatization. Chapter 13 discusses the way trauma therapy affects the therapist and chapter 14 looks at the factors in the therapist and in the therapeutic situation that contribute to vicarious traumatization. Vicarious traumatization may be defined as the transformation of the inner experience of the therapist that comes about as a result of empathic engagement with the client's trauma material. This review would be incomplete without an overview of the concept discussed in the book. The authors emphasize that vicarious traumatization results in profound disruptions in therapists frame of reference, that is his basic sense of identity, world view and spirituality. The concept is unique to trauma work. It's effects are specific and pervasive and it inevitably affects all our relationships- therapeutic, collegial and personal. Unlike countertransference, vicarious traumatization is not specific to one client or therapeutic relationship; rather it takes place over time, across clients and therapeutic relationship. The authors press home the advantage of understanding this concept when they emphasize that unaddressed vicarious traumatization can affect the therapist's ability to live fully, to love, to work, to play, to create. It can lead the therapist to leave the field, sets the stage for burnout due to lost sense of identity as an effective helper, because of the demoralization and 'soul sadness' that characterize the spiritual damage of vicarious traumatization. There is thus an authoritative description of this concept and the reader would come through with a feeling that doing trauma work should be a informed choice because of the strong implications for the therapist concerned. It is difficult to conceive in a medical model that the act of giving treatment can have such profound personal ramifications, hence viewing the therapy in a relational model is essential for understanding trauma therapy.
Part four [Chapters 15 and 16] is devoted to the interaction between countertransference and vicarious traumatization. This is brought out beautifully by the authors as they point out that vicarious traumatization represents changes in the most intimate psychological workings of the self of the therapist and the self of the therapist is the context for all countertransference. Thus vicarious traumatization invariably shapes countertransference. On the other hand, a therapist's countertransference can set the stage for particular vicarious traumatization responses. For example, when immersed in countertransference response or enactment with a client a therapist's intense feelings may reduce his self awareness. In such a state , a therapist is especially vulnerable to the erosion of his cherished beliefs and values which is a hallmark of vicarious traumatization. Thus countertransference and vicarious traumatization can intensify, moderate or set the stage for one another throughout these therapies. This interaction creates a spiral with potentially disastrous results for the treatment, resulting in therapeutic impasse. In addition, it can result in increased vicarious traumatization with dire consequences for the personal and professional life of the therapist. Thus as the authors point out that both countertransference and vicarious traumatization are inevitable processes in psychotherapy with adult survivors of childhood sexual abuse and as such the therapist attunement to her influence on the therapeutic relationship and the impact of her work on herself is essential to the maintenance of a therapy that is respectful to and safe for both participants.
The fifth and final part focuses on therapist self care. Given the nature of work as trauma therapist taking care of one's own psychological well being is not only desirable, it becomes imperative. Chapter 17 is devoted to supervision and consultation for trauma therapies. The authors have emphasized the necessity of self care for therapist's doing trauma work and they lay out useful guidelines and specifications for the same. They write that trauma therapy supervision should be considered as clinical supervision with specific modifications. Four components are specified:
1] A solid theoretical grounding which comprises theoretical understanding of psychotherapy in general and trauma therapy in particular.
2] A relational focus that attends to both conscious and unconscious aspects of therapeutic relationship and treatment process.
3] A respectful interpersonal climate that allows attention to countertransference and parallel process.
4] Education about and attunement to the therapist vicarious traumatization.
They argue that all therapist's have an ethical as well as personal responsibility to engage in regular frequent clinical consultation on their psychotherapeutic work; a minimum of an hour weekly for an experienced clinician and more for newer clinicians is invaluable to the therapist and his therapies.
The second chapter [chapter 18] in this part is devoted to addressing vicarious traumatization and ways to counter it's potentially deleterious effects on the clinician. The primary concepts discussed by the authors here are practical, informative and imperative for therapist's who engage in trauma work. These are:
1] Awareness of oneself, one's needs, limits and resources.
2] Balance among work, play and rest.
3] Connection with oneself and others is the antidote to the isolation that can come about through vicarious traumatization.
The third and last chapter [chapter 19] in this part talks about rewards of doing trauma therapy. As the reader approaches the final chapters of this book , he may be reflecting on the various professional and personal implications of doing trauma work. Just then the authors encourage us when they talk about the rewards of doing trauma therapy. In fact they emphatically talk about the positive choice of their career and convey that there is no other work that they would find this meaningful, challenging and rewarding. They further discuss the rewarding aspects in relation to the client, their own self and society as a whole and write thus:
Transformation of our clients: when our clients grow and heal we are rewarded.
Transformation of the therapist as therapist: fascinating to discover how the human mind works, how creative and resourceful individuals can be and many natural mechanisms that can be activated to protect the self. Many teachers of psychotherapy have taught that a client will transform his therapist so that the therapist can give the client what he needs.
Transformation of the therapist as a person: sharing in the growth and development of another person is an honor and these therapies are characterized by a unique depth of intimacy. We feel nourished by such connections and have increased respect for the human spirit
Rewards for the therapist as a member of society: The work of a trauma therapist is the work of a revolutionary. Our work serves not only to heal those who have been harmed, but also to protect their children and to break the cycle of abuse that silence and shame engender. It is deeply satisfying to contribute to breaking a malignant cycle by doing trauma therapy with survivor patients and therapists.
The book ends with the appendix which has two measures developed at the Traumatic Stress Institute [the private institute where the authors work]:
The TSI Belief scale is a measure of disrupted cognitive schemas.
The Life Orientation Inventory is measure of spirituality.
Who should read this book? This book is a must for new trauma therapists as they would encounter many difficulties in therapy and would be encouraged by the comprehensive coverage which resolves many a difficult issue. Both experienced therapist and experienced trauma therapist would benefit by the in-depth handling of therapy related issues. Students of psychotherapy would be much better informed about relevant topics.
For those considering trauma therapy as a career this book is a gift. It would help make a informed choice, so necessary, considering the nature of work involved.
To sum up, this book is lucidly written, authoritative, well researched, and gives trauma therapy a new perspective in that it gives importance to both, the therapist as well as the client in therapy. Somewhere, the reader also begins to sense the strong commitment of the authors towards the care and treatment of adult survivors of childhood sexual abuse. It is definitely a book worth possessing for professionals related to the field of trauma therapy.
Dr. Sonali Jhanjee is a senior consultant psychiatrist, with a special inclination in forensic psychiatry. She has worked as a senior resident at the department of psychiatry, Guru Teg Bahadur Hospital and Associated University College of Medical Sciences, Shahdara, Delhi. She can be contacted at firstname.lastname@example.org.
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