General Principals in Trauma Healing

October 21st, 2010

General Principals in Trauma Healing

The abusive experiences usually observed by therapists in a domestic setting range from emotional deprivation to various forms of emotional abuse, such as constant verbal criticisms, and in more serious cases include physical or sexual violence.

While the latter clearly falls under the category of “abuse,” certain types of neglect or abuse are chronic and insidious, such as the toxic relationships therapists observe between patients with borderline personality disorder and their parents.

Sometimes caretakers collude passively in the abuse rather than actively, yet in so doing they allow or even enable the abuse to continue.

If an innocent citizen has been victimized as a result of a caretaker’s betrayal or negligence, normal assumptions about trust and safety have been violated.

An example of this is the case I describe in my book of a schizophrenic patient whose husband as well as the Child Welfare caseworker and psychiatrist allowed her to be with her children without supervision, while psychotic, and with a previous conviction of child battery.

In short, the lack of diligence by designated caretakers resulted in the death of the child.

This principal has political and social significance. A caretaker’s primary responsibility is to protect the welfare of the individuals or communities under their trust.

This model of moral responsibility applies not only to parents, but to mutual caretaking between spousal partners; or at a collective level, a government towards its citizens.

Mental health professionals involved in trauma healing have to, before anything else, establish a secure environment conducive to a climate that allows recovery to begin.

The empathic bond established early in therapy may constitute the first building block in replacing the victim’s sense of chaos and danger with that of order and predictability.

The microcosm of safety in the therapeutic relationship, however, can only be effective if it is supported on the outside by a safe social infrastructure or “holding environment.”

In certain hostage situations there may be no real safe haven for the victim.

Young victims, having never been properly soothed, may never learn the capacity to self-soothe.

For this reason, trauma therapists need to be kind, supportive, and empathic.

For the healing process to succeed, victims need to have an emotional sense of being “held” or comforted by others.

This makes it easier for victim patients to share their stories in the comfort of “someone who is on their side.”

Gradually, patients are able to internalize this sense of safety they feel with their therapists.

This reattachment to a trusted caretaker (who reawakens schemas of “the good parent”) empowers victims to engage the world with an enhanced sense of personal efficacy.

In trauma recovery, the cornerstone of treatment is providing an environment that is physically and emotionally safe. Only when convinced by an empowered, benevolent caretaker (such as a psychiatrist or trauma recovery group) can victims begin to safely reclaim personal agency.

The feeling of safety must encompass the survivor’s social, political and religious life, where the umbrella of protection encompasses a newfound confidence of expression in an environment free from external threat.

Therapists also need to constantly confirm that it is indeed safe for the victim to now engage in new patterns of thinking.

The victim may need reminding that it is permissible to assert and express one’s own belief system.

This creates an uncomfortable paradigm shift for the predator that controls the power dynamic through emotional threat: “Know that any attempt at autonomy will have dire consequences.”

In early development, a healthy parent allows a child to individuate while responding supportively to any frustrations the child experiences when leaving the safe haven to engage the world.

Originally, the parent or other caretaker laid the foundation for determining feelings of safety, self-worth, sense of agency, and ability to own and assert personal rights in any relationship.

Many traumatized individuals lack the confidence and sense of well-being required to protect themselves against the exploitations of predators.

Victims will now have to summon these resources to free themselves from the external triggers that have controlled them.

The trauma therapist will function as a catalyst to create a safe holding environment that will mobilize rescue functions.

These skills, once learned, have to be applied to use newfound supports.

This concept also applies at the collective level, where protective social and governmental agencies play the caretaker role in protecting citizens from internal (domestic) or external security threats.

Self-Psychology and Trauma Healing

The psychological theorist Heinz Kohut emphasizes that once the self is damaged healing cannot take place through interpretation alone, but rather requires a healing interpersonal relationship.

Many victims a sense of being emotionally disconnected from a world which is no-longer safe.

The school of Self-Psychology insists that healing can only occur through a process of empathic sharing between the therapist and the victim. Until this occurs, abuse victims may be weary and guarded, reluctant to share their horrors with anyone.

During professional training, the school of Self-Psychology develops a skill set in therapists who have a positive propensity to empathic healing based on their own innate sensitivity to others.

Traumatized patients need their therapists to have harnessed their empathy into a didactic set of skills.

As an authentic patient-therapist relationship develops, the victim begins to feel safe.

Instead of remaining in the traumatized state of fear or emotional isolation, something resembling “good parenting” allows victims to gain a sense of self.

According to Kohut, for this to occur the therapist has to allow the patient to dwell in and consolidate the relationship (Kohut, F. The Restoration of the Self. New York: International Universities Press, 1977).

Eventually the patient “micro-internalizes” the good qualities of the therapist, who functions as a good “self-object.”

This requires the therapist to bring sufficient emotional resources into the relationship to provide a safe “holding” environment.

In certain victims of child abuse, this is the therapeutic process that allows recovery from the early self-object failures of caretakers.

In addition, the therapist needs to bring a skill set to the victim that allows a greater pain tolerance to help the survivor begin to face the real challenges of everyday life.

Once the victim has been soothed, he or she will need to learn how to self-soothe.

So, in a sense, the therapist needs to function in the dual capacity of caretaker and instructor.

Without this process, the danger exists that the therapeutic relationship will become dominated by powerful emotions of a dependency type.

The Psychodynamic school of therapy refers to a victim’s regressive state of continued dependence on the “good therapist” as an idealized transference reaction, i.e. the “good parent.”

The therapist should note that significant transference does takes place in many victims of chronic neglect or abuse.

When a therapist becomes drawn into a rescuing role, there has to be a loss of therapeutic neutrality.

In this regard, the didactic skill sets established by Marsha Linehan begin to define a template for the components in the repair of chronic trauma.

She addresses how trauma triggers elicit the maladaptive cognitions, emotions, and behaviors that we find in the victim of chronic psychological trauma (Linehan, M. Skills Training Manual for Treating Borderline Personality Disorder. New York: The Guilford Press, 1993).

During the healing process, any safe means that aids the victim in “self-soothing” is helpful.

This might include exercise, painting, meditation, yoga, martial arts, dance, or prayer, among many other possibilities.

The capacity to self-soothe is largely determined by early developmental factors which pertain to early attachment, foraging patterns, and many other nuances that may lead to caretaker failure.

There are significant implications that pertain to the cause and context of psychological trauma.

Emotionally healthy adults show more resilience in accessing good self-attributes as well as mobilizing external resources in the face of trauma.

Adults that were emotionally deprived or exposed to impaired caretakers lack this resilience.

When the trauma cascade cannot be regulated, previously traumatized individuals are less able to identify and respond effectively to predators.

Under conditions of stress-reactivation, they are prone to emotionally regress into a repetitious pattern of maladaptive behaviors.

When the victim has been failed by caretakers in the past, “self-psychology” may be a vital ingredient in stabilizing self-functions by providing the victim with a form of surrogate parental “holding.”

Rational and adaptive behavior is greatly enhanced when a victim internalizes the positive “self-object” component of the (good parent) surrogate while acquiring techniques, such as “anchoring” and “mindfulness,” and becoming problem-orientated rather than helpless.

Self-soothing functions are also crucial for brain structures to perform the tasks required in synthesizing trauma narratives.

Psychodynamic Therapy

M. J. Horowitz, the most noted psychoanalytic trauma therapist, has outlined the principals involved when applying the traditional Psychodynamic  model of psychological trauma (“Signs and Symptoms of PTSD.” Archives of General Psychiatry 37, 1980).

This model attempts to explain that until the therapeutic work of trauma resolution is accomplished, unresolved trauma material will continue to surface in the form of “intrusive symptoms.”

The therapist practicing Psychodynamic Therapy will attempt to identify the array of defenses (“repression” in particular) that the victim utilizes to defend his ego against traumatic memories. This also provides an explanation for the “avoidance domain” of PTSD.

While trauma victims ultimately have to come to some form of peace with their personal trauma narrative, their trauma symptoms may be missed for several reasons.

One reason includes post-traumatic amnesia, discussed elsewhere under the title “dissociation.”

Another reason abuse is missed is that victims may engage in a process of “rationalization.” Some victims believe that their tormentors were “too kind to have done that to me.”

This often happens when the abusers were parents, spouses, or other close family members. These relationships are dominated by unconditional loyalty and abuse victims may remain in a state of denial regarding their caretaker’s betrayal.

These terms were all discovered by Sigmund Freud and published in the Complete Psychological Works of Sigmund Freud (Standard Edition. Hogarth Press, 1953).

Victims of chronic abuse may feel so demeaned, their feelings invalidated, their sensitivities dismissed, and their pride so demolished that they fail to develop a healthy sense of autonomy, empowerment, or sense of personal agency.

Such victims often fail to understand why they cannot experience trust or true intimacy.

Abuse victims may avoid social engagement because of fear and distrust, while turning to their therapists to provide excessive hands-on rescue functions. The therapist may unwittingly become ensnared by these positive projections.

The therapist then runs the risk of acting out personal rescue fantasies by becoming the “idealized good parent.

Other trauma victims sabotage their relationships with therapists who are insufficiently available as part of a recurring pattern known as “trauma reenactment.

This occurs when the trauma victim uses negative projection in relationships where the therapist is induced into acting out the schema of the “bad” or withholding parent.

In psychodynamic training, therapists are trained to identify and analyze their own response to the victim’s projections.

These are some of the issues that become the focus of treatment when using the Psychodynamic approach.

Notwithstanding the valuable contributions of these other methods, the Psychodynamic school continues to offer a valuable model in the understanding of trauma and recovery.

Trauma Group Therapy

The Group Trauma Recovery model of therapy can be used either alone or as an adjunct for victims who are engaged in individual therapy.

In providing a safe environment, the therapist’s function (to some extent) is to assume a caretaking or even parenting role.

When good “parenting” skills are used to create a safe holding environment, healing can take place via bonding and vicarious learning from other group members.

For such victims, the group provides a safe haven removed from a world otherwise dominated by fear triggers.

There are recovery groups for victims of rape or adult victims of child abuse, as well as those for veterans returning from active tours of duty.

Victims feel less isolated about the secrets of their personal burdens once they begin to learn from each other’s experiences. In addition, there is a relief effect of sharing.

The common cause of trauma binds the victims, who now recognize that they share a common experience.

The victim group should be as homogeneous as possible.

During the first stage, trauma narration is discouraged because not all members have yet acquired the coping skills to absorb trauma narrations which trigger their own trauma recollections.

Until all members feel ready to process trauma-laden material, they must learn various coping skills, e.g. boundary preservation and interpersonal respect.

The prevailing “ground rule” is that each victim’s sense of safety has to be respected.

Grounding techniques such as controlled breathing and the use of any self-soothing objects that reactivate early comforting experiences are encouraged.

The trauma-group will then need a vocabulary to allow victims a description of their personal horror-story.

Co-therapists can be useful to identify distressed victims and facilitate natural bonding and the group’s capacity to heal.

The therapists meet separately, and quite frequently, to assess the progress of the therapeutic group process.

They decide at which point the group is ready to enter the “trauma narrative” phase of therapy.

As this begins, the therapists should educate the trauma group about trauma triggers and undesirable emotional responses, such as fear or anger. Maladaptive behaviors will be compared with more functional strategies that reestablish a sense of calmness and well being.

Follow-up studies of traumatized victims show that most “intrusive” symptoms in the immediate aftermath of a trauma, if untreated, are replaced by numbing, constriction, social avoidance, and even physical symptoms over time.

This can be prevented when the victim is able to bond with other victims.

The goal is to eventually have each victim hear others tell their story while they feel supported by the group.

Simultaneously, the therapist creates an environment that is both therapeutic as well as safe for the entire victim group.


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