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Hello, here we are at the very first Shrink Thinks Seminar!
Please be sure to submit questions, topics, suggestions, or prompts that will help this space be pertinent to your work and practice. I will keep them confidential for all involved and extrapolate the essential themes so that these explorations will be useful for all of us.
The topic for this week’s session is regarding trauma work, and taking on this work when the psychotherapist is a trauma survivor themselves.
So: essentially, we will be exploring issues pertaining to the clinical manifestations of trauma, countertransference, vicarious traumatization and retraumatization, identification and over-identification, self care, corrective experience and meaning making.
First let me suggest that trauma is a common, natural and ubiquitous experience. Everyone will experience trauma at some point in their lives. All children have some degree of traumatic experience (although not every child experiences severe trauma or severe abuse) , and that it can erupt anywhere, at anytime – so its important to remember that any “non-traumatic” case can become a trauma case. And any non-traumatized therapist (do any exist?) can have a re-organizing traumatic experience.
I’m not a big DSM person, and chances of you ever seeing me cite it again are highly unlikely – but I do find its definition of traumatic events and exposure helpful:
Criterion A (one required): The person was exposed to: death, threatened death, actual or threatened serious injury, or actual or threatened sexual violence, in the following way(s):
- Direct exposure
- Witnessing the trauma
- Learning that a relative or close friend was exposed to a trauma
- Indirect exposure to aversive details of the trauma, usually in the course of professional duties (e.g., first responders, medics)
So: really, by this definition, the every day realities of living and dying and suffering and injury are traumatic. Seeing a dead body, hearing that a loved one experienced an accidental amputation, car accidents, witnessing an assault. Trauma, on some level, is simply being reminded, viscerally or vicariously in one way or another that we are breakable and that we die, and that we do not control our own fates or the fates of those we love. Traumatic violence/abuse is also a reminder that human beings are capable of behaving immorally, which creates an experience of traumatizing existential “horror.” Trauma is a reminder of the precariousness of life, and the frailty of our civilizing moral norms – and that exposure to reality perforates our wish to live a safe and domesticated life and often destabilizes us for a while, as in acute traumatic response, or destabilizes us in ways that become disabling, as in post traumatic disorder. Trauma is a reminder that life is feral, and not tame.
So: surviving trauma is not inherently pathological even if it is extremely painful and upsetting and traumatic response falls along a wide spectrum of adaptive, generative, creative, empathic, to reactive, anxious, fearful, avoidant, sleepless, dissociative, rage-full, destructive and adrenalized.
And sometimes all of the above occur at once, or sequentially in any given individual.
I also want to say this: trauma and traumatic response leave a permanent imprint in the psyche and in the body. That imprint, that scar, that crack, or that open wound is the aftermath of a core annihilation anxiety which erupts once it activated by the traumatic event. Annihilation anxiety is programmed into us as a species, (and animals can carry life long traumatic imprinting as well obviously) in service of our survival and longevity.
“Disordered” traumatic response is actually an expectable common severe response to severe trauma and results in symptoms which may cause significant distress for ourselves or others, disrupts our survival skills and endangers our relationships to others. And even when that is the case, those who have survived severe trauma often have compartments of extremely effective functioning that are then derailed by episodes of traumatic dysregulation.
Traumatic response has an indelible protective purpose, even if in severe cases it isn’t serving its purpose effectively. It doesn’t disappear, we can’t get rid of it and we can’t “cure” it.
I remember once in social work school, I was in class with Dr. Judith Mishne – who was stern, exacting, imperious (some might say egotistical), and brilliant. (And who became a very generous advisor to me in my early career). She presented a case of a client who was facing overwhelming anxiety coming out as a lesbian, who also had a history of severe physical and sexual abuse by her father. A student asked if there was a way to determine if the client was “really” gay or if perhaps her “current” sexual identity was “only” a response to heterosexually perpetrated abuse. And Mishne’s mildly irritated response was this:
“Who cares? It doesn’t matter! Trauma of this nature is as permanent and inviolate as someone having blue eyes or being born gay. This trauma is as indelible a part of her identity as any inheritable quality. You can’t undo history or genetics. The only question is how can she find a way to live with it?”
I remember that this was a very important notion for me at the time. I had imagined in my earlier years in my own therapy that I should and would eventually be “cured” and that I was in training to “cure” others. And this was when I realized that my task was really to form an adaptive, generative relationship with my own trauma history.
This is the nature of sublimation – we don’t ever rid ourselves of our core injuries but we might be able to learn to live constructively, tenderly, creatively alongside them, to form an internal alliance with our traumatized selves. And of course entering into healing work, and trauma work is one way of accepting our trauma and trying to make healthy use of it, to live with it, to partner with it.
This brings us to the archetype of the Wounded Healer. A book that I highly recommend to anyone in any helping profession is Adolf Guggenbühl Craig’s: Power in the Healing Professions – a challenging exploration of the positive and negative archetypes that surround the role of Healer – savior, charlatan, quack, magician.
Here is what he has to say about this archetype:
Here we encounter the archetype of the wounded healer. Chiron the centaur who taught Asclepius the healing arts, himself suffered from incurable wounds… The mythological image of the wounded healer is widespread. Psychologically this means not only that the patient has a physician within himself but also that there is a patient within the doctor. p 84
There are genuine wounded healers among analysts, there are constantly analyzed and enlightened by their parents. Such an analyst recognizes how the patient’s difficulties constellate his own problems and vice versa, and he therefore works openly not only on the patient, but on himself. He remains forever a patient as well as a healer. p.120
“Physician heal thyself” in this context is not a commandment to perform a finite act to completion and be done with it. It is an instruction to all healers to undertake this work, continuously over a lifetime, and a warning that unless you are actively engaged in the ongoing act of tending to your own wound, your inner patient tenderly, kindly, firmly – your clients will never be able to summon their inner physician and heal themselves in your presence.
So making use of your own trauma to support other’s in their healing processes is on one level a potentially healthy, adaptive and potentially corrective undertaking, but of course it is also hazardous:
Psychotherapist are in danger of not only of harming our clients but also harming ourselves by vicarious traumatization – or by flying too close to the sun, and becoming grandiose in relationship to our knowledge and familiarity with our own wound. We can over identify with client’s whose path toward integration may be very different from our own. Some will need to sublimate it. Some will need to dissociate and compartmentalize. Some will need to avoid, repress, ignore it. And others will need to repeat it, living out the traumatic content over and over – in an attempt to master and gain power over the experience that nearly annihilated them.
We hope that by offering our client’s a sense of containment (“holding” in Winnicotian terms) that clients will be able to withstand the almost alchemical burning process that may transform an experience of annihilation into something that can be lived with, contained, and held by the client.
But some trauma, especially severe, cumulative and compounded trauma can crack our containers in ways that are irreparable. And this is true for physicians and patients, psychotherapists and clients.
This is an important essay on this subject by my friend and colleague Jason Mihalko PsyD. Dear Young Therapist: Sometimes We Can’t Put Humpty Dumpty Together Again.
Please read it.
Some of the most painful clinical failures I have experienced have occurred when I hoped too much that I could lift someone out of torturous, pernicious compound trauma, and by hoping too much failed to stay with them or failed to help them find any comfort at all.
And so we come to self-care: which does not, in my mind, refer to a list of self-pampering activities but about engaging in healthy, and humbling non-therapeutic processes and relationships. Transactions that that keep us connected to our “inner client” and compensate for the savior complexes that are activated in the consultation room, combating the hubris which is instilled in us by clients idealizing desire to see us as saviors and our wish to save them by imagining our own trauma is “behind us.” Non-therapeutic processes, learning experiences that press us into beginners mind, things we cannot do well, that are complex enough that we cannot evade our vulnerability and we are able to be nurtured, taught, instructed: Painting, dance, artistic endeavors, meditation, language learning, martial arts, religious and spiritual practices. Practices that we cannot be “good” at easily, that we will never master, that take our power and skill set away, that call on us to experience our shames, our inhibitions, our self-criticisms, our inner editors, our woundedness and challenge us continue to heal ourselves.
Guggenbühl-Craig suggests that the most essential antidote to this is to surround oneself with non-professional relationships, intimate friendships with others who are in no way impressed by our insight or hoodwinked by our therapeutic skill – mutual relationships of balanced power with those who love and accept us but know our broken places and see them more readily that we can ourselves. Loving relationships keep us in touch with our own vulnerability, make us laugh at our own foolishness and shrink us down to size.
The greatest, ultimate danger in undertaking trauma work as a trauma survivor is evading our own healing by focusing instead on the wounds of others.
Physician, heal thyself.
Next Seminar session will be posted at the end of May!