This is a beginning to intermediate level course. After completing this course, the mental health professional will be able to:
The materials in this course are based on the most accurate information available to the author at the time of writing. The field of trauma psychology grows daily, and new information may emerge that supersedes these course materials. This course material will equip clinicians to have a basic understanding of trauma and its effects, and how to assess those effects across a broad range of diagnoses. This content may provoke painful feelings for some readers, or bring the reader’s own personal trauma experience to mind.
This is the third of three courses in a series about trauma, a biopsychosocial/spiritual-existential phenomenon whose effects can be seen in the forms of distress and dysfunction on almost every variable of human function. The first course, Becoming a Trauma-Aware Therapist: Definitions and Assessment, covers questions of what constitutes a trauma, and how to assess for its effects in a range of ways. The second course, Treating Trauma: Basic Skills and Specific Treatments, introduces an overarching framework for trauma treatment, and then reviews the large variety of specific treatments for trauma that are now available. This third course, Cultural Competence and Humility In the Trauma-Aware Therapist, explores being sensitive to the patient's multilayered cultural identities when being treated for trauma, as well as that of the therapist working with the trauma patient.
Countertransference is a reality in psychotherapy. Whether or not your theoretical orientation has an explicit reference to the construct, what is true is that all psychotherapies, including those interventions that are largely about medications, are encounters between human beings, who come to those encounters fully loaded with personal histories, feelings, and needs. Thus, therapists have feelings about our clients, some of which are immensely helpful to the therapeutic endeavor, others of which are potentially harmful or even destructive when unexamined and misunderstood by the therapist. Some therapists are trauma survivors and know it, others are trauma survivors and do not yet identify their life experience within this rubric, while some have little to no history of trauma exposure. All of these aspects of therapists’ histories factor into how they sit with the client who is identified as a trauma survivor. It is in the nature of working with trauma survivors that such therapist feelings are more present, more powerful, and more challenging than may be the case with other clients because of the intense nature of the material and the dynamics of post-trauma responses.
Encountering these unwelcome emotional aspects of the therapist’s self has a troubled history in the mental health disciplines. Like many psychologists trained in the middle of the last century, I was given the message that such emotions were a problem, likely a result of my own unresolved conflicts, and that my job was to confront and work through them in my personal therapy so as not to burden my clients with the projections of my own materials. The notion that psychotherapists could, and ought to be, objective, dominated that discourse and continues to influence my generation of Baby Boomer psychotherapists, despite the growing body of evidence to the contrary.
Many other psychotherapists insist that they do not experience or need to deal with countertransference because they are not psychodynamic – and similarly assert that there is also no transference in the therapy because it is not focused on exploration of unconscious processes. Some writers have argued that if one is doing a cognitive or behavioral therapy that this, per se, obviates the problem of countertransference; somehow, these therapists believe that if their construct does not include attention to less adult emotions or symbolic representations in relationships that these are simply banished from the room.
I join with Dalenberg (2000), who is the foremost scholar of countertransference issues in trauma treatment, in eschewing both of these viewpoints. After intentionally working with trauma survivors for four decades prior to retiring from clinical practice (and unintentionally doing so for far longer), I would argue that while all of our clients are likely to evoke some kind of strong emotions from us at some points, clients with a history of trauma are more likely than most to do so. Why might this be? The simple answer is that everything about trauma has the potential to evoke some kind of powerful response in other human beings. Whether we turn away, become numb, get emotionally activated or sexually aroused, rescue, judge or blame a victim, we are demonstrating those responses.
As Dalenberg (2000) has cogently noted, “trauma victims figure prominently in virtually every well-known therapeutic dilemma or disaster associated with strong countertransference reactions.” (p.12) She goes on to say that “psychotherapists often have countertransferential reactions to the fact of trauma…the psychotherapist’s pre-existing thoughts and beliefs about the trauma may affect the course of therapy greatly.” (p. 13, italics in original) Many of these problematic psychotherapist responses to work with trauma survivors reflect the experiences of fear, terror, disgust, shame, and powerlessness felt by the psychotherapist in the face of their client’s powerful feelings and apparently unreachably self-destructive behaviors. They are also resonances of clients’ own feelings about the trauma, and often of their feelings about themselves and their own experiences of trauma exposure.
All of these responses are human. When I train therapists to work with trauma, I often share my own experiences of going numb, fighting off sleep, and writing grocery lists in my head when first hearing details of traumas that pushed me beyond my then-capacities to know of the cruelties of the world. I talk about my urges to rescue, the foolish things that I have done when faced with the power of post-traumatic emotions sweeping over my client and me like a tsunami. Each therapist, no matter how experienced, will feel such things repetitively throughout a career, as capacities to witness trauma change due to personal life experiences or the very real effects of working with trauma survivors. Most therapists, upon encountering these responses within themselves, feel ashamed, guilty, or both, adding emotions to the mix that confuse, frighten, or alienate the survivor client.
Consequently, a necessary step in using the countertransferential material of trauma treatment in ways that assist the therapy is to accept its presence, warts and all. Pope and Tabachnick (1993), in their classic article, “Therapists' Anger, Hate, Fear, and Sexual Feelings,” found that more than 80% of their participants, all practicing psychologists, reported experiencing each of these fears with at least one client, and most with many of their clients. Clearly such emotions are normative, no matter who the client is. With trauma, however, other emotions emerge as well.
What therapists working with trauma bear witness to is terrible. Trauma is cruel; it is profoundly random and irrational. It breaks the heart and, with repetition, can harden it. A child goes to school; an earthquake occurs, the roof falls in and crushes her. She survives with the memory of the cries of her dying classmates in her ears, and her own terror of believing that she will never be found. A man goes to work; an angry former co-worker storms in and shoots people in front of him. The sight of blood pooling around his desk, and the smell of his own body sweating in fear both haunt him as he returns to work each day. A woman marries; her husband beats her bloody, for no reason and every reason, beginning on their wedding night. A decent law-abiding man and a violent felon are both crew members on a fishing boat; it sinks, and only the violent man survives. A father rapes his daughter repeatedly. A priest molests an altar boy, who for the rest of his life becomes nauseous each time he attempts to take Holy Communion. A young woman joins the military to get money to go to college; her best friend’s brains are blown out all over her when a mine explodes their truck as they deliver supplies to the forward base in Faluja; then her buddy in the motor pool sexually assaults her. Some or all of this material is in a day’s work for psychotherapists working with trauma survivors. For a therapist to remain stoic in the face of this sort of material would be inhuman, and could be evidence of a neurobiological shut-down that disconnects the therapist somatically from the client in ways that will be destructive to the therapeutic alliance.
Readers are likely, at this juncture, to wonder why it was necessary to write things in this most blatant and painful manner. Could I not simply refer to sexual abuse, intimate partner violence, combat trauma – the various covering terms that allow us to communicate to clients our desire to not necessarily hear or know the details of their lives? This is precisely the point I hope to make here. One of the most common countertransference responses that therapists have to their clients’ material is the desire not to hear or know the details when a client is in need of sharing them. A problematic set of therapist behaviors emerging from this mirrors the numbing and avoidance engaged by trauma survivors themselves as coping strategies; these responses are toxic to therapy.
Constance Dalenberg (2000), who has conducted extensive research on clients’ and therapists’ experiences of trauma-related countertransference, relates a number of poignant stories of trauma survivors whose therapists were so numb to their stories that they repeatedly failed to listen, forgot that they had been told painful details by the client, or in some instances discouraged the client from telling his stories. Therapists frequently couch their avoidant strategies with clients in terms of attempting to spare the client from having to speak of the trauma. This does not help clients. While forcing clients to speak of the details of their trauma before they have safety and stability, and before they are themselves ready to share that information, is also problematic (and is addressed below); silencing a client who is ready to speak and wishes to be witnessed constitutes a form of retraumatization and empathic failure that usually leads to clients exiting treatment prematurely.
In my own early intentional work with trauma survivors, this theme of being silenced by previous therapists emerged frequently, with one client (Brown, 1986) speaking of how her initial post-combat therapist ignored her burgeoning alcohol abuse, and added benzodiazepines to the mixture so that she became too numb to function, much less talk about her traumatic experiences as a nurse in Viet Nam. When she re-entered therapy a decade of addiction later, she not only had to deal with her PTSD – she also had to live through the painful process of recovery from substances, and the added shame that her addiction brought to her. Silencing our clients makes them pay an even greater price for trauma.
Therapists who are tied to the notion of therapeutic objectivity or neutrality may be particularly at risk for this kind of trauma-related countertransference. If one is struggling to keep oneself non-responsive in the face of painful material, one is much more likely to avoid that material or become internally numb so as to continue to present a facade of unaffectedness. However, no therapists, no matter how much their theory values genuineness, are immune. Specific issues can evoke our avoidant strategies. The first time we hear the story of an incest survivor from our own ethnic group where the mythology is that such crimes are not committed by our group; the day that we have received our own diagnosis of a serious illness and our client is speaking, once again, of their own diagnosis; the day the client who shares our demographics and is experiencing the kinds of loss that we thought our life circumstances and privilege protected us against; all of these and more can engender avoidant responses. Context affects our ability to hear and know material.
A sub-theme of the avoidance dynamic is that of disbelief. Some of the things that happen to trauma survivors beg belief; this is especially true when we work with survivors of severe childhood abuse, trafficking, torture, or extreme intimate partner violence. Additionally, because of the nature of a trauma, the developmental stage at the time of its occurrence, and the nature of the interpersonal context while the trauma was happening, many trauma survivors’ stories include improbably bizarre material, which feeds avoidant disbelief.
Imagine this scenario: a client tells you that her former husband has hacked her computer, and bugged her house and car. You would likely think that she was delusional. This, however, is the actual fact pattern of a forensic case in which I was involved, with every detail corroborated by police reports and forensic evidence including the photos of the phone in situ. Or this: a client tells you that she was passed around by her incestuous father to different men, who took photos of her having sex with them and their own children. This story sounds bizarre, until you read the law enforcement case file on the pedophile ring of which her father and his friends were a part, or unless you have worked with enough trafficked people to know that this is a common story of their childhoods. If the Nazis and the Khmer Rouge had not been such meticulous documenters of their genocidal practices, who would credit the stories of the survivors of the Nazi and Cambodian holocausts? In the case of the Khmer Rouge, it was only by luck and happenstance that a handful of people survived the notorious Tuol Sleng torture chambers to tell their story. The Killing Fields of Cambodia and the concentration camps of the 1940’s, each of which I have visited, are now often pleasant-looking grassy mounds where birds and butterflies festoon the air; the horrors visited in those now-calm locations seem beyond belief.
Not only do the details of many trauma survivors’ stories leave us wanting to avoid their experiences via disbelief (or its cousin, minimization – “it couldn’t have been that bad”), trauma therapists have, in the last three decades, worked within a context of a social movement whose entire goal was to discredit adult survivors of childhood sexual abuse, and blame therapists for the reports of such abuse. Therapists’ fears of being sued by their adult clients’ parents escalated during the 1990’s due to well-publicized litigation being brought by a few of those parents. While the frequency of these cases has reduced, as recently as January of 2011, a jury in Wisconsin found a therapist liable to his client’s parents because he had failed to “disabuse” the young adult client of her beliefs that she had been incestuously abused. Fortunately, this movement has now disbanded; while its few adherents remain and do their best to promote this now-discredited narrative, the scientific basis for understanding delayed recall has become too strong to ignore as we enter the third decade of this century.
This persistent fear by therapists that they will be sued for believing, or will create a so-called “false memory” if they do not disbelieve, adds weight to the avoidant pull to not believe. While no therapist is in the position of knowing what truly happened to a client, all therapists are in the position of being able to empathically acknowledge the emotional truth of a client’s suffering. When, however, a therapist is avoiding the immensity of pain being expressed by a client, the “disbelief” stance is one that can create distance for the therapist. Therapists should be relieved that the False Memory Syndrome Foundation has ceased to exist, no longer funding a network of attorneys and experts in search of possible cases.
The therapist’s job is not to act as the arbiter of the client’s reality; to decide for our clients what is narrative truth about their lives is hubris at its worst. But as Dalenberg notes, “It is crucial during this negotiation (between belief and doubt) that the clinician respect the bravery of the client as she or he breaks silence and asks to be believed.” (2000, p. 113). Distancing from the emotional truths of what clients experienced means that they feel abandoned by their therapist – and not because they have issues with abandonment, but because the therapist will have in fact abandoned them emotionally.
The rise of so-called “reality” television demonstrates how powerful the draw of prurient interest is. We claim not to watch shows on which people’s emotions are laid bare for all to see, but the ratings tell the truth. Psychotherapists are no more immune to this than are any other people; in fact, some would argue that our interests in the details of other peoples’ lives lies somewhere in the outer limits of decency. Therapists are curious about people, and our work gives us license to ask intrusive, embarrassing questions about the most intimate details of clients’ lives, to know their secrets. We may experience some discomfort about this, but for the most part the degree to which psychotherapy is invasive of clients’ privacy is taken for granted by therapists. So long as we contain the material within the bounds of confidentiality, psychotherapists generally give little thought to the ways in which our work violates typical conventions of interpersonal disclosure. “TMI,” the colloquial term for having shared too intimately with others, is the usual content of psychotherapy sessions.
These disclosures also constitute some of the foundation of the power differentials present in therapy. Our clients tell us these intimate details of their lives. We, for therapeutic, ethical, and personal reasons, tend to tell them little or nothing about our own. While this is not an argument for self-disclosure, which may or may not have a place in any client’s therapy experience, it illustrates the difference in vulnerability that is normative in therapy. When therapists use that structural imbalance in order to satisfy their own curiosity, clients are not well served.
One of the great secrets of trauma work is that some psychotherapists find the details of our clients’ traumas exciting, titillating, or even arousing. The client has experienced things that are the stuff of novels and movies, has lived in realities that may be exotic to us, albeit in a horrifying way. The therapist has permission to ask questions, and when prurient curiosity is the motive, instead of inquiring in the service of the client’s welfare, we do so to scratch the itch of wanting to know “all the gory details” when the client is still not ready or able to be that exposed.
This particular dynamic unveils itself most commonly in a therapist’s assertion that the client must tell all details of his trauma story immediately in order to get better, often alluding to the notion that keeping secrets has been part of the traumagenic nature of the experience. The therapist pulls for details, “How did you feel when he did that? What did she say?” when there is no therapeutic rationale for knowing that specific information at that point in treatment, or perhaps ever. Clients often comply, even against their own better judgment or desires, wishing to please the therapist, and hoping that the intrusive questions will cease. This itself constitutes a form of trauma reenactment in which the more powerful person violates the emotional boundaries of the one with less power, a mirror of what occurs in the trauma experiences of many survivors.
Leaving aside those therapists intentionally utilizing Prolonged Exposure (PE), which does require clients to write out a very detailed narrative of their trauma, most approaches to trauma treatment do not require this kind of blow-by-blow accounting of the psychic blows suffered by trauma survivors. Clients describe these kinds of therapeutic encounters as violating, and often experience shame at their difficulties in complying with therapist requests/demands for full disclosure of details when it is not the client’s desire to share that information.
This particular countertransference also emerges in the form of violations of confidentiality. The therapist knows details of a titillating story. This person observes the forms in telling it at home or a party; the client’s name and occupation are stripped out, but the details remain. Entertainment value is increased when particularly interesting details are available to share. Therapists who are themselves involved in high-profile cases are also at some risk; the wish to require disclosure of more than is needed therapeutically so as to heighten one’s own narcissistic pleasure at being in the know about the famous or infamous person in our office can be difficult to resist.
It is normal and human for a therapist to feel curious, aroused, or excited by a client’s trauma story. These feelings may even be helpful to the therapist’s capacities for empathy with the client, as clients themselves may have had such feelings which they then deem inappropriate, and about which they feel shame. Therapists should always be mindful of the “cui bono” question when asking for further information, and consider whether their request will assist the client, or serve as a reminder that the client, by entering the realm of trauma survivorship, has become a curiosity to others, an exhibit on the stage of reality. Trauma reenactments of this sort undermine the therapeutic alliance, and thus the process of recovery.
Trauma survivors threaten the rest of humanity. They are a reminder that the just world can and does blow up at any time, of the vulnerability of humans in the face of large natural events, or of the ways in which the person we believed loved and cared for us can betray and harm us. Trauma survivors often challenge their therapists. They don’t trust us (nor should they at first; we are, after all, total strangers to them); they engage in behaviors that are apparently self-destructive in the service of affect regulation and self-soothing. They demonstrate their learned helplessness via what appears to be passivity or stuckness. They become “irrationally” angry with us, no matter how much we care and how hard we work, and fail to appreciate our care, concern, and personal sacrifice. In other words, they do all of the things that survivors typically do to manage affects and relationships, the very phenomena that have pushed them in to our offices. Therapists become frustrated – we feel unappreciated, manipulated, and just plain angry. These feelings are normal, but when enacted, they become problematic.
Sometimes, how a therapist responds to these realities of the difficulty of subject and client is via attack and blame of the client. But because we are therapists, these countertransference dynamics usually come cloaked under therapeutic rationales – “confrontation,” “avoiding dependency,” “getting clients to take responsibility for their lives,” or “setting clear boundaries.” As I’ll discuss later in this segment, therapists engaging in these behaviors are often entering into a trauma reenactment with the client, in which they play the role of a perpetrator. Trauma survivors, because of their hypervigilance, are more likely than most clients to notice the therapist’s feelings, even when the therapist denies that they are present. The therapist who is denying being angry when asking clients “what do you think you could have done differently” when they were being sexually assaulted, or “how long do you think it will take you to finally forgive that drunk driver” to the client whose need to use a wheelchair for ambulation was a result of the accident is not simply engaging in behaviors that are known to be detrimental to the therapy. That therapist is also conveying to the trauma survivor client that the client is having wrong feelings, wrong reactions, and wrong needs about what has happened. The therapist who says, “Call whenever you need to,” and then becomes short and snappy when the client believes and acts on this offer, is communicating that the client is too much, often precisely what a trauma survivor often fears to be true.
Again, therapists frequently hide behind the cloak of neutrality and objectivity when delivering hostile comments. Therapists may also code their hostile withdrawals in terms of “encouraging client autonomy.” Therapists may also, depending on their own personal dynamics, enact hostility in a passive-aggressive martyred manner, sharing too much personal information about how tired, stressed, or over-worked they are in such a way as to convey to clients that they are the source of the stress and fatigue. This is not to say that a therapist ought never to disclose being tired or off-center. A therapist can deliver this information in a way that clearly demonstrates care and compassion for the client when asked the standard “how are you” question. “You may be picking up that I’m a little tired today, and I am. This isn’t about you, and you don’t need to take care of me. I just didn’t want you wondering if my energy today was about you, because it’s not.” Contrast this with, “You know, work is pretty stressful. I’m glad I could be available to you when you called last night, but I think I might have stretched myself a little too much; I’m pretty tired today. But don’t worry.”
We will be angry while sitting with our trauma survivor clients – at the universe, for what happened to them, at the individuals or institutions who harmed them, at a system that has failed them, and at them for how they behave. Such anger can be used therapeutically, with appropriate consultation and support in its employment in the service of the treatment. Blaming our trauma survivor clients for what has happened to them, or for the difficulties they encounter in healing from trauma, may protect therapists from our own feelings of vulnerability, just as numbing and distance do, but these dynamics will certainly undermine the therapy.
Therapists working with trauma survivors feel guilt and shame in our relationships with our clients. We feel guilty that we have not suffered as our clients have, even if we ourselves have a trauma history, and guilty that we cannot help them fast enough or more effectively. We feel guilty that even if we have suffered, our lives now work better while our client continues to struggle and suffer. We then resent our clients for “making” us feel guilty. We feel shame that we were angry, aroused, avoidant, or fearful. We then withdraw, distancing from the source of the shame, attack its source (our client), punish ourselves for feeling shame, or attempt to deny its existence. We feel ashamed for our clients’ vulnerability, weakness, and fear; we feel ashamed of them. Because, through our work with trauma survivors, therapists are associated with this stigmatized group, we experience referred stigma.
Guilt and shame have their place in a therapist’s emotional lexicon. We need not feel guilty about guilt, or ashamed of shame, any more than we benefit from feeling any of the other human response to our clients’ experiences, symptoms, and dilemmas. So how to manage these, and other affects, without undermining clients’ sense of safety in the relationship?
For these and so many other reasons, compassion for self becomes a necessary ingredient of the work of psychotherapy. First, self-compassion allows therapists to respond effectively to the range of emotional responses discussed earlier. When we both normalize these emotions, and then also observe ourselves mindfully and with compassion for our terrible humanity, we soothe and center ourselves.
We also gain invaluable experience with the power of compassion to heal. Many trauma survivors enter therapy with little-to-no compassion for themselves, embroiled in dynamics of self-blame, self-attack, and self-shame, along with their own avoidance and dysregulated arousal. When we, as therapists, are unable to experience compassion for our own fears and foibles, our trauma survivor clients will inevitably sense this, and find our exhortations that they have compassion for themselves hollow.
Compassion is not, however, license to act out our emotions with our clients. It is, rather, permission to experience our feelings, have them fully, and inquire into how those inner realities can deepen empathy and inform us about our clients’ experiences.
As noted in the discussion above, one of the patterns into which all of these common therapist responses fit themselves is that of the trauma reenactment with the client. Such a reenactment is characterized by four roles; each player in the reenactment can, and will, switch between roles during the course of an extended interaction such as psychotherapy. The job for trauma-informed psychotherapists is to identify when they and their client are engaged in this dynamic, and move to the side of it.
Trauma reenactments occur repeatedly in the lives of many trauma survivors, particularly those whose trauma has been interpersonal and occurred at younger developmental stages. They reflect a number of variables. These include the survivor’s comfort with familiar relational dynamics, even when those dynamics are destructive, because such dynamics have a feel of rightness, reflecting the distorted post-traumatic view of self, others, and the world common in many trauma survivors (Brown, 2015). Additionally, they pull on common human responses to trauma survivors, including all of those found in psychotherapists. As many authors about trauma treatment – including Briere & Scott (2006), Courtois (2009), Dalenberg (2000) and Pearlman & Saakvitne (1995) – have noted, what is surprising in a course of therapy with a trauma survivor is not that a trauma enactment occurs, but rather that the therapist is unprepared, and often filled with guilt and shame about having become a part of this dynamic when he at last notices it occurring.
The roles in the trauma reenactment are the Victim, the Rescuer/Martyr, the Abuser/Perpetrator, and the Helpless Bystander. Some readers will recognize the first three as coming from the Karpman Drama Triangle, which describes a non-trauma-related interpersonal dynamics as well. The role of the Helpless Bystander is trauma-specific, and is a sub-category of both the Abuser/Perpetrator, in that in this role the player is neglectful, and a sub-category of the Rescuer in which the Rescuer, exhausted and feeling hopeless, has given up.
Trauma survivors in a reenactment generally start in the role of Victim, which needs to be distinguished from having genuinely been victimized by trauma. Given the reality of victimization, it is relatively easy for the survivor to occupy this role. What distinguishes the role from the traumatic reality can sometimes be subtle and initially difficult to detect. It is most easily seen as role through the reciprocal responses of the therapist, and from the way in which the traumatized person shifts into another one of the positions in the reenactment.
Therapists most commonly situate initially in the role of Rescuer. In this position, therapists may over-extend, offering time and energy that they truly do not have available to give. This leads to position shifts; if resentful, the therapist moves into Victim, putting the client into the Perpetrator role. Former Rescuers may experience themselves as martyred, misunderstood, or unappreciated by the client, leading to the kind of acting out of hostility described earlier in this segment.
The Rescuer therapist can also move into the role of Helpless Bystander, which can be both a passive-aggressive act of hostility against a client, or a response to despair and the belief that nothing that the therapist does can help. In the former instance, the therapist may fail to make safety plans with a suicidal client, “forget” to get paperwork submitted in a timely fashion so that the client loses benefits, or, under the guise of empathy, affirm to client that they are indeed, as they have feared, too broken to be helped. In the case of the former, the therapist may simply cease to behave in an effective manner in sessions, passively allowing things to occur that make the client into an Abuser, or failing to intervene when it is appropriate. Therapists in this position often speak of feeling confused, overwhelmed, and simply not knowing what to do.
One of the interesting behaviors of a Bystander reenactment occurs when a therapist has made an error, and then glibly accepted a client’s easy forgiveness of the mistake rather than taking initiative to repair the rupture well. When clients are survivors of developmental and/or interpersonal trauma, they are accustomed to placating people in positions of power and authority, minimizing the ways in which they have been hurtful to the client out of fear of activating the powerful person’s narcissistic wounds, which would then lead to further pain for the trauma survivor. As we’ll discuss below, countertransference and other therapist errors can become very helpful to the therapy when the therapist attends to them carefully and uses them to affect a true relational repair. But when therapists are Bystander to their own trespass and then collude with the client in letting themselves off the hook, then clients begin to sense, sometimes without giving words to it, that they are not emotionally safe and begin to withdraw, sometimes dropping out of the therapy not long after.
This role switch can also occur between the therapist and colleagues or institutions. This most commonly happens when a therapist chronically goes above and beyond the call of duty, and then becomes allied with the client as co-victims against other therapists who “just don’t understand,” or a system that fails to adequately support the therapist-client dyad. This is not to say that therapists are not truly exploited by unjust, underfunded systems, or misunderstood by colleagues who fail to appreciate the vicissitudes of trauma work, any more than trauma clients are not genuinely victimized by their trauma experiences. Rather, the reenactment dynamic reflects a fundamental flaw in how these therapists have positioned themselves vis-a-vis their work. This almost always begins with a history of over-extendedness.
Finally, the therapist can move directly into the role of Abuser/Perpetrator. As described above in the section on blame and hostility, this role finds the therapist behaving in sadistic ways toward the client. The therapist who sexually acts out with the client is also in this role.
What is essential to understand about trauma reenactments is that almost all trauma-informed therapists will find themselves beginning to be drawn into these dynamics with trauma survivor clients. We have powerful, well-learned, and sometimes evolutionarily-coded response patterns to wounded and vulnerable people, and the demand characteristics of an interpersonal relationship with a trauma survivor will point the therapist to one of these positions. All of the common countertransference responses to trauma occupy one of these roles; thus, a full comprehension of those common patterns is extremely helpful in mindfully and compassionately noticing oneself in a trauma reenactment and stepping aside from it, repairing the ruptures emerging from it and offering clients a different outcome from what was a difficult starting point relationally.
It is also important not to blame the client/trauma survivor/victim for pulling us into these roles; doing so is to move into the Abuser/Perpetrator position, and become part of a reenactment. Clients will often frequently experience the therapist as being in the Abuser/Perpetrator or Helpless Bystander roles when their non-conscious fears about the therapist are stimulated by events in the therapy. One trauma survivor client of mine became enraged when I expressed feeling sad at hearing her experiences, insisting that this was a violation of her. She had been forced, among other things, to be her father’s emotional sounding board, and could not distinguish at that point between an empathic expression of genuine feeling for her and a narcissistic hijacking of her time and attention. In that moment, I was the Abuser/Perpetrator, no matter what my intention had been. Had I become angry, done a one-up interpretation of her anger, withdrawn emotionally, or otherwise not simply responded by working to repair the empathic breach, I would, however, have actually stepped into that role, punishing her for rejecting my offering of care. If I had needed her to accept that care to soothe myself, I would have been in the Rescuer role; caring, without being attached to whether she liked how I did it, was being a therapist.
Normalizing this interpersonal dynamic – similar to normalizing the occurrence of trauma-related countertransferences – increases the likelihood that the therapy will only be temporarily affected by such patterns of interaction. One of the manners in which trauma reenactments can be detected is that they frequently involve violations of the boundary and frame of therapy, a topic we will discuss next. The road out of trauma reenactments will be discussed in the final component of this course segment on making effective use of therapist errors.
“If you really don’t think I’m disgusting, you would have sex with me.” My client, a dissociative survivor of childhood sexual and physical abuse and neglect, must have made this statement monthly in the first years of our work together. When, several years into treatment, she realized, through careful attention to cues, that my long-time committed relationship had dissolved, she reiterated her insistence that now that I was single, I should act like anyone who genuinely cared for her, and comply with her request for a truly intimate, thus sexual, relationship.
My consistent, careful, compassionate refusals of her request were met with episodes of suicidal self-injury, attacks of rage, or long periods of sullen withdrawnness. In her childhood, she had made herself safe from beatings and starvation by offering herself sexually to dangerous adults; my refusals to accept her offers were experienced as abandonment, betrayal, and willingness to let her be harmed. She employed a number of strategies: telling me that the rules (aka the Ethics Code) were more important to me than she was, that I was simply trying to protect myself, and that, of course, I didn’t care about her. In other words, she experienced me as an Abuser/Perpetrator, even as I was firmly refusing to become one.
Yet it was my steadfast assertion that even though I knew that my refusal was painful for her, I would never intentionally do something that I knew could harm her. That became the touchstone of my role as a consistent, benign figure in her inner world, one that she much later credited for our being able to do the work of integration and trauma resolution. She often commented in the latter part of our work together that she had finally gotten it that genuine care always meant refusing to do something that I knew would harm her, even if that refusal was painful, and that she could finally feel safe in knowing that, not just with me, but in the world.
Many trauma survivor clients will seem to push on therapists’ boundaries, intentionally as well as accidentally. Reciprocally, it is common for therapists working with survivors to violate boundaries in the midst of some kind of reenactment. The work of Pope and his colleagues finds that few therapists are well-trained to deal with boundary issues. Boundaries in therapy are experienced by many therapists as arbitrary rules that must be followed in order to manage risk and stay out of trouble – in other words, in a compliant, rather than a genuinely comprehended, manner. Thus, when the situations of the trauma survivor appear to require a violation of the boundaries, the therapist may privilege what appears to be compassion or flexibility over being law abiding.
A more effective strategy for understanding boundaries in psychotherapy has to do with noticing how boundaries are about instituting safety and stability for the client; they are about providing safe-enough relationships, which are the cornerstone of therapy. Therapists provide these basic needs to our clients by having integrity, being reliable, predictable, and willing to model impulse regulation on behalf of the welfare of the client and the therapy relationship. Thus, time boundaries of sessions are not in place simply because that is how time is billed. They exist to protect the therapy relationship for this client – because the therapist has had ample time to recharge and recycle between sessions – and the next client – because that next person knows that their time is also sacred and almost entirely inviolable except in the case of genuine emergencies. The money boundaries are in place so that there is an energetic exchange between the parties; each one gives something to the relationship. Fees are negotiated and waived from time to time to reflect clients’ financial circumstances. Therapists, however, do not make a practice of endangering their own financial welfare and safety, as it is very difficult to provide safety to a client when one’s self is unsafe. The boundary about not having social or sexual relationships with clients is not there just because the rules forbid it. It is so the interpersonal space of the therapy, like the time, is also sacred, not infiltrated by the concerns and self-interest that will inevitably emerge between friends or lovers. It is also there in service of the therapist’s well-being, to make available spaces in life in which one can be one’s complicated, inconsistent self without the risk of harm to a vulnerable client.
In short, the boundaries of therapy are there as expressions of therapists’ care and respect for our clients, and therapists’ commitment to safeguard the sacredness of the therapeutic relationship. The Hebrew word for sacred, “Kadosh,” derives from a word root meaning “set apart,” and it is within this epistemic framework that therapists set the space of therapy apart. When a trauma-informed therapist is able to see how the boundaries of therapy are themselves therapeutic stances that are there to support the development of safe-enough attachment, rather than rules added on to the “real” work of therapy, it becomes immensely easier to not accept invitations to participate in trauma reenactments.
Boundaries of therapy vary from one theoretical orientation to another. Rigid adherence to a boundary when flexibility or compassion is appropriate is itself a form of boundary violation. As Ochberg, one of the founders of modern trauma treatment, pointed out long ago (1988), a therapist working with trauma survivors cannot be neutral, behaviorally or morally, as moral neutrality is the functional equivalent of silently standing against the survivor in the Bystander position. There will be times when a therapist who has a norm of not touching clients may find it the morally non-neutral thing to do to hold on to a client’s hand as that person is living through a flashback or sobbing in grief. There will be times when a therapist who always and only works within the 50-minute session framework will book regular double sessions with the client whose developmental trauma has shut down Broca’s area, making speech slow and painful. Each one of these “boundary crossings,” as they are referred to, must not be done impulsively, although they may occur spontaneously. The therapist must take the time, however briefly, to consider how this is indeed right, and not rescuing, and then have a discussion of the boundary crossing and its meanings to both parties, as well as with a consultant, at the soonest therapeutically appropriate moment.
Therapists are human beings. We are sleepy, inattentive, ignorant, or just plain make mistakes. We get sick or hurt. Some of us give birth or adopt children. Our relationships end, our parents become ill or die. Trauma survivors, often mired in self-blame, will frequently attribute our errors, whether countertransference enactments or completely accidental, to themselves and their spoiled identities. As noted above, they will too quickly let the therapist off the hook. Conversely, the trauma survivor may move into the Abuser/Perpetrator position and lash out in anger at our failures. Trauma reenactments will emerge.
These are potentially fruitful turning points for therapy when the therapist can recognize them and step out of the trauma reenactment. This requires the therapist to be competent in mindful self-soothing and compassion for self. It is, after all, not easy to sit across from someone who is blasting you profanely for having made a mistake and maintain some form of humility and equilibrium, and neither grovel nor defend. It is even harder to sit across from someone in pain over what we have done and not rescue, over-apologize, or gloss over the importance of what we have done.
Stepping out of the trauma reenactment requires self-awareness as well. We need to know what the emotional and embodied markers are of our own forays into the roles of the reenactment. I have found that a certain warmth behind the eyes is a sure-fire precursor to my being about to engage in a rescue, while a particular tone in my voice and a feeling in my vocal chords signals me that I’m on my way to being punitive. Therapists need to also be able to have insight into how they make their most common errors.
Even when the error was made from a position of care, as was true for the client to whom I expressed sadness, I needed to understand what had happened for me to repair with my client. I realized, and shared with her, that I had not only reenacted her abusive relationship with a parent. I had also stepped in much closer emotionally than she felt safe with me doing, and she needed to push me back, hard and fast, in order to feel safe. I had been insufficiently attuned to the ways in which she was managing distance and closeness, and privileging my sense that we were too distant. This is not a grave error; on the 10-point scale of erroneous therapist behaviors, this was perhaps a 2, for me. Nonetheless, it was on the scale, which is what mattered to me. My taking responsibility, not glossing this over because it was “only” a 2 for me, although something closer to a 10 for her, and soothing myself so that I could fully engage with the repair of the rupture, stepped both of us out of the chasm of the trauma reenactment that was starting to loom between us.
Engaging in repair with a trauma survivor client at these moments of therapeutic rupture can be a profound and powerful thing for a therapist to do. The work of repair may be long. With this particular person, it was several months before she could accept that I was not intentional in my violation of her space, or angry at or rejecting of her for having pushed me away. With other trauma survivors, the work of repair can occur more rapidly. I find that this transparent, calm, and willing embrace of my own humanity is an effective modeling strategy with survivors who have adopted perfectionism as their defense against further trauma, and thus have little to no compassion for their own human flaws and frailties.
We will next discuss a particular focus for countertransference – that of cultural competence and humility. Working with aspects of clients’ intersectional identities that are not our own can evoke countertransference responses that are more shame-inducing and difficult to handle. Cultural competence and humility thus enhances emotional competence, and the ability to know and effectively use countertransferential materials.
Trauma occurs within the psychosocial framework of external cultural realities, and the internal, intrapsychic representations of those realities. A child who is being repeatedly abused and neglected; an adult trapped in painful and apparently inescapable intimate violence, or held captive and tortured; a man whose legs are blown away by a roadside bomb in Iraq; or a family losing their home to an earthquake are not generic human beings experiencing these traumata. They are always people who are unique, and sometimes uniquely targeted for traumatic experiences because of aspects of their intersectional identities, those various strands of self that make up each of our sense of who we are in the interpersonal world. These survivors, and we, their therapists, then experience the distress of the trauma, and attempts to cope with that distress, in the psychosocial realities of a particular time, place, and location in the social and political world. Finally, trauma-aware psychotherapists are themselves also the product of this process of identity development in the context of cultural and social realities; we have our own intersectional identities. We represent meanings to trauma survivors that may assist, or undermine, the development of a therapeutic alliance and the conduct of psychotherapy itself.
Responding effectively to these realities in clinical work requires the development of cultural competence and humility by all trauma-aware psychotherapists. This goal has often seemed daunting largely because of how cultural competence has most commonly been defined, and has led many to distance themselves from work with individuals who they perceive as different in some way that might preclude competent practice. The notion that competence is equivalent to humility, and is a conscious embrace of a life-long stance of having something new to learn, can be a difficult yet rewarding one to adopt. This stance is not unique to trauma work; such distancing, often accompanied by feelings of guilt, shame, and inadequacy, is as normative among many clinicians when issues of difference become foreground as distancing from trauma survivors has been for those psychotherapists to whom post-trauma presentations seemed alien or overpowering. Feeling incompetent, and not wishing to admit to one’s ignorance, can induce shame, along with its distancing effects. A goal of this segment of the course is both to disrupt the common narrative of how a psychotherapist develops cultural competence, as well as to engage clinicians in the project of becoming culturally competent in their work with all of their clients, not only those marked as different in some manner. The keyword to this entire project is humility; one must be humble in the face of the vastness of ignorance that each one of us, regardless of our particular intersectional identities, brings to bear upon the project of connecting across apparent difference.
I’ll be focusing here on an inclusive paradigm for cultural competence and humility that can, and should, be woven into the fabric of the specific treatment models addressed earlier in this course. Our focus is on creating heightened awareness of one’s own inevitable biases and distortions, and on developing overarching epistemologies of difference rather than algorithms for working with so-called “special populations,” and models of intersectional identities as they affect both the experience of trauma and the later development both of distress and dysfunction, as well as resilience, hopefulness, and post-traumatic growth.
Why should a trauma-informed clinician be centrally concerned with becoming culturally competent and humble? Why not simply take the stance of referring the survivor who is a member of group “X” to the specialist in that group, and maintain competence and ethical practice by means of limiting the populations with whom one works? Or see all clients as simply human, and take a stance of “color-blindness”? Why not feel satisfied with what we know, rather than embracing the reality of our ignorance and unknowing?
First, this is essential because more than is true for any other form of psychic distress, the very nature of trauma is inherently concerned with culture, context, politics, and identity. Much trauma is interpersonal in nature, and each person comes to the experience of trauma, whether as perpetrator or target, as a human with identities and social realities that, if denied, can silence the survivor just as surely as denying the trauma itself. Many traumas, particularly complex traumas, are those of enforced intimacy, of shared physical and social realities, and frequently of shared or overlapping cultures and meanings. Trauma is flavored and shaped by those psychosocial, contextual, political, and cultural milieus in which it occurs. Ironically – within a subject matter that is itself a voicing of previously silenced realities – culture, identity, and social context have largely been the invisible components of conceptualizations of working with trauma survivors until the early decades of this century.
Second, because for those readers who do not live in large metropolitan areas replete with specialists in working with every possible population, the option of making a referral to such a specialist is not an option, and even then not always a good idea. “Referring you out to the specialist” is another way of conveying to a trauma survivor that they are uniquely bad or hard to deal with. This strategy is itself a means of emotional distancing from difference. Finally, this strategy reflects an epistemology of difference that, while revolutionary and highly valuable in its day when first introduced into the psychotherapy professions, is no longer a tenable stance for understanding human difference, nor a foundation for culturally competent and humble practice. It “ghettoizes” the experiences of those whose intersectional identities appear to differ from the dominant cultural norm, or from our own. All of us have every single marker of identity present in ourselves, and to routinely decline to work with people who do not appear to share all of our identity markers and knowable intersectionalities reduces our capacities to thoughtfully and critically interrogate those markers in ourselves, and in clients who appear to resemble us.
Mental health coursework and textbooks on working with difference have commonly used the term “minority group” to refer to those populations who are defined as “other” from the author. I will not be utilizing that terminology, as it is both numerically inaccurate in many instances, and also carries a meta-message that is experienced by many members of these groups as pejorative, e.g., “less than.” Instead, I will be using the terms “target” and “agent” group. Target groups are defined as those groups in a given cultural and political setting that have been historically, and/or are currently, the targets of systemic discrimination, violence, and/or prejudice. Agent groups are defined as those groups in a particular cultural and political setting that are defined as the norm, and which possess power within the hierarchy and institutions of that setting. Most individuals contain some mixture of agent and target experiences within their identities. These group memberships, while they may be founded on biological variables such as sex or phenotype, are socially constructed, and differ from context to context. They are then given meaning and value by the specific cultural, social, political, and existential realities in which a person exists; as such, these meanings and values may change as the narrative themes of those settings transform. Trauma survivors constitute one large, diverse target group, marginalized by a dominant culture that wishes to obscure the realities of trauma, loss, and the unpredictability of life. Aspects of identity intersect within each person; Crenshaw (1989) coined the term “intersectional identities” to refer to the lived experiences that all humans have, be they aware or otherwise of our mix of locations on various social dimensions.
Beginning in the 1960s, literatures emerged in the various mental health disciplines noting that the science and scholarship of those fields were distorted through the lenses of dominant cultures, with almost everything written about human beings reflecting, in reality, only the experience of humans who were male, Euro American, and middle class – members of the cultural dominant groups of the United States, in other words. The decades of the 1970’s and 1980’s were marked by an explosion of scholarship on the psychological experiences and needs of target groups, with volumes dedicated to women, African-Americans, lesbians and gay men, older adults, people with disabilities, and other similar specific target groups.
This sort of scholarship, which focuses on within-group similarities, as well as differences between target and dominant groups, is referred to as an etic epistemology. Etic strategies for knowledge are those emphasizing allegedly objective collections of information about a group based on categories of analysis developed from outside of the group. In the instance of this “Handbook of psychotherapy with aliens” period of scholarship, the etic knowledge offered about members of target groups referred to how they did or did not fit into dominant culture diagnostic categories, and how they did or did not respond to conventional, dominant culture approaches to psychotherapy.
Cultural competence within this etic epistemology of difference required clinicians to acquire large amounts of information about specific groups, developing sets of clinical rules and algorithms for working with clients who were group members. Humility was never considered a good thing. Etic epistemologies and the scholarship arising from them tended to downplay within-group differences, emphasize the homogeneity of groups, and highlight the differences between target and dominant groups. Assumptions that were implicit in this scholarship included that group membership was always a core and foreground component of an individual’s identity, and that target group memberships were relatively fixed, rather than fluid, categories of experience. Culturally competent practitioners in this model would thus have specific limits to their competence, being able, for instance, to work well with one unique group of aliens. Some states even offered certifications for clinicians as specialists in work with a particular group of Others.
Etic models of cultural competence were important and necessary correctives to the state of the mental health disciplines prior to the last third of the 20th century, an era when all behavioral norms were defined unquestioningly through those of agent groups. They were a valuable and irreplaceable initial step in moving these disciplines and their practitioners toward the capacity to work with people from the full range of human experience, punctuating as they did the varieties of human experiences and the diversity of idioms of psychological distress and behavioral dysfunction.
However, these etic models were also problematic in some important ways. Problems included unquestioned assumptions about the value of standard diagnostic categories and practices. Etic models simply demonstrated, for the most part, how they applied poorly to members of some target groups, rather than raising more fundamental questions about the inherent value of those diagnoses or therapeutic strategies that might have had implications for working with all clients. A sort of conceptual ghetto was created in which the “diverse populations” literature flourished, but spilled out little into the dominant culture of the mental health disciplines.
Etic models also have had another, extremely unfortunate set of unintended consequences. By creating a standard for competence that was based upon the acquisition of specific knowledge, many clinicians defined themselves as not competent to work with members of most target groups, and, in an attempt to practice ethically, withdrew from working with such individuals, feeling uncomfortable and, in some instances, ashamed of not knowing the correct information. Humility was penalized, not seen as a foundational value for doing this work.
For these reasons, and because of changes in how the study of difference has been approached since the late 20th Century, emic epistemologies of difference and human diversity have emerged in the mental health disciplines as a different paradigm for culturally competent practice. Emic models do not assume an invariant human behavioral norm or standardized categories of understanding and analyzing human experiences. Nor do they place authority in the hands of the external expert. Rather, they are more qualitative and phenomenological in nature, assuming the presence of within-group differences that are meaningful to individuals in those groups even if they are not easily apparent to outside observers. These models invite the development of categories of analysis of experience from within a group, disclaiming the existence of the objective or universal. Emic models create an epistemic framework in which members of target groups are themselves the experts on the realities and meanings of their experiences, and in which the experience of intersectional identities is normative and assumed, rather than denied, as is often the case for members of agent groups who have not yet interrogated their own internal variability.
Additionally, within the mental health disciplines, these models have emphasized the importance for clinicians of understanding and interrogating the meaning of our own identities and biases, as well as the implications of those variables for the accurate observation of the distress of others and the design and implementation of healing strategies. Thus, emic models are not simply about understanding the alien other; they are also about understanding being human, and about apprehending the intersubjective meanings for all parties of being a psychotherapist of particular intersectional identities working with a client with other or similar intersectional identities. In emic models, both parties are observers, and both parties co-construct the meanings of experiences.
Emic models do not assume a stance of expertise on the part of the clinician, but rather, a stance of curiosity and ignorance, frequently referred to in the literature as “cultural humility.” This position of humility has come to increasingly be recognized as an important foundation for culturally competent practice. Culturally competent therapists know and embrace the reality that they are indeed ignorant, lacking in sufficient knowledge of the person of the client. They embrace the ambiguity of the psychotherapeutic situation, and create space in which to compassionately, and without judgment, experience how they may fail in their understanding of their clients, both because they are apparently different, as well as because they are apparently similar. Embracing ambiguity and having humility about cultural phenomena with all clients is a component of cultural competence. Deepening these capacities will assist in the implementation of the evidence-based therapist variables underlying trauma treatment that were discussed earlier.
However, the effects of guilt and shame that are frequently distorting dynamics in relationships between target and agent groups seem to disconnect otherwise emotionally skilled psychotherapists from their willingness to be uncertain and tentative with clients who represent the Other to them. Psychotherapists frequently experience themselves as more different, more deficient, and less competent to consider engaging with clients who visibly differ from them. In trauma-informed work, where the psychotherapist’s own emotional responses are more likely to be carefully scrutinized and interpreted by clients whose experiences have been dangerous and confusing, the presence of such distortions, and the performance anxieties placed upon themselves by psychotherapists, can lead to serious, difficult-to-repair ruptures in the therapeutic alliance. Consequently, a step toward the development of emic cultural competence for psychotherapists is the direct confrontation of, and acceptance for, the realities of one’s own bias.
As people of good will, psychotherapists tend to see themselves as non-judgmental and lacking in malignant bias. We are, in many instances, trained to become aware of our judgments and let them go, and cautioned to maintain neutral, objective stances in relationship to our clients. This narrative of the unbiased, non-judgmental psychotherapist is deadly to the development of cultural competence, as it presumes a way of being that is difficult, if not possible, for most human beings to achieve.
Evolutionary biology and psychology indicate that human beings are coded to notice difference. Our limbic systems, which are also implicated in the trauma response, light up and become active when data become available in the interpersonal field informing us that another human differs from us in some way. Our limbic system overpowers our cognitive brain, firing more quickly than our orbital pre-frontal cortex. The notion that a psychotherapist can be unbiased presumes the absence of limbic system input, as well as of any personal life history that has ascribed meaning to difference, either positive or otherwise. No psychotherapist matches these criteria.
By the time that our first client, not to speak of trauma survivor, enters the office, the average psychotherapist will have had multiple experiences of classically conditioned associations with the visual, auditory, kinesthetic, and other sensory cues presented by that individual. The psychotherapist will have bias simply by virtue of being human. Acknowledging this reality is akin to acknowledging any sort of affects evoked by our clients, as discussed in the section on countertransference.
Yet when the client is identified as a member of a target group, and the therapist’s identity is largely that of agent group status, these awarenesses of the normative nature of therapist bias and negative affects in therapy are often over-shadowed by therapists’ feelings of guilt and shame for experiencing those emotions toward the client whose group has been targeted. These affects are components of a larger phenomenon known as “aversive” or “modern” bias (Gaertner & Dovidio, 1986, 2005), an understanding of which is another core aspect of developing cultural competence.
Aversive bias refers to non-conscious biases held by individuals who consciously eschew overt expressions of bias. A split emerges in many individuals between their expressed, conscious beliefs, which are not biased and emphasize the value of fairness, and their well-conditioned, non-conscious, and now ego-dystonic biases, which are consciously aversive to them. Social psychologists who have studied this phenomenon suggest that around 85% of Euro-American individuals hold aversive bias towards persons of color, for example, even though their consciously held attitudes and behaviors are devoid of overt bias.
Aversive bias has observable impact on interactions with others; thus, it is not simply a private affair, but rather an intersubjective phenomenon with specific effects on the interpersonal field. Given the sensitivity of many trauma survivors to a therapist’s own unexplored or denied feelings, it stands to reason that aversive bias can play a large part in undermining therapeutic relationship, and thus effectiveness.
Aversive bias is supported by denial and undoing, and leads to shame, discomfort, and distancing by agent group members from target group members. Members of target groups, who, like trauma survivors, are often highly attuned to cues about bias emanating from members of dominant groups, will commonly experience their interactions with such agent group persons as crazy-making and fraught with inauthenticity, just as the psychotherapy client encountering a therapist who claims to have no angry feelings while emitting cues of angry affect feels discounted and crazy-made.
Dovidio and his colleagues, in a series of elegant experiments exploring the effects of aversive bias, have paired African American individuals with Euro American individuals on a problem-solving task. The Euro American participants were assessed on measures of both overt and aversive bias, and divided into three groups: Low aversive/low overt bias, High aversive/low overt bias, and High aversive/high overt bias. They found that African American participants had the most difficult time interacting with the middle group, finding it easier to relate to a person who was consistently high in both conscious and non-conscious bias than to deal with the conflicting psychosocial cues emitted by the individual who was unconscious of his aversive bias. Persons in the middle group tended to behave in ways that were inappropriate for the situation; they were either overly friendly, leading to suspicion regarding motive on the part of the African American participants, or became withdrawn and almost punishing, apparently when their inauthentic attempts to create relationship were unsuccessful. (Readers wishing to assess their own levels of aversive bias on the variables of ethnicity and sex can do so for free, and anonymously, online at understandingprejudice.org).
The implications of these and similar findings for the psychotherapeutic relationship are potentially quite powerful. Psychotherapists who are unaware or in denial of their aversive bias may, like the participants in Dovidio’s studies, emit interpersonal cues that undermine their conscious intentions to do well. Given the heightened importance of the therapeutic alliance for clients who have anxious or ambivalent attachment styles, which is true for many survivors of interpersonal violence trauma (Norcross & Lambert, 2005), the presence of such non-conscious and disowned bias in the psychotherapist may be particularly toxic to the alliance in psychotherapy with this population.
Cultural competence does not rest solely in knowing in theory that one has aversive bias, however. It requires humility, a willingness to acknowledge this fact about oneself compassionately, without shaming oneself or inducing guilt in oneself, as a step toward greater congruence, humility, and authenticity. As noted above, humans are biologically wired to respond to difference, and psychosocially conditioned to associate difference with negative ascriptions that are inescapable in the familial and cultural contexts in which each psychotherapist has been raised. Since virtually all humans have bias, acknowledging that reality about oneself enhances the therapist’s capacity to work with clients whose intersectional identities differ visibly from their own and particularly enhances emotional competence in work with trauma survivor clients.
Shame about bias, however, undermines effectiveness. Nathanson (1992) has argued that humans have four predictable responses to shame: withdrawing or distancing from the source of the shame, attacking the self for being shameful, attacking the source of the shame, or denial. Each of these interpersonal and intrapersonal strategies is counter to psychotherapeutic effectiveness. Compassionate acceptance of the reality of psychotherapist bias allows for approach and relationship between agent and target group members, no matter which one is the therapist and which the client, an interpersonal style more consistent with the development of a therapeutic alliance. If I am able to accept the reality of my biases, and make them conscious in a mindful and compassionate manner, I will enact them less, distance less from clients who evoke these biases because I am experiencing less shame about my own responses, and be more willing to be confronted by a client without responding in a defensive manner. Cultural competence and humility about one’s humanity creates therapeutic competence.
When psychotherapists embrace the reality of their bias without shame, then they are free to take the next step toward cultural competence – the acknowledgement of one’s cultural privilege and disadvantage. Neither privilege nor disadvantage is earned or deserved; like the acquisition of bias, the experiences of privilege and disadvantage accrue to the individual because of the circumstances and realities of her life, few of which, until adulthood, occur in response to her own desires or actions. While the term privilege has become radioactive in some circles in recent years as conflicts within the larger social context have worsened, the term is used here in a purely descriptive manner, to which no judgment accrues. We all have privilege of some kinds. We all have disadvantage of some kinds. In our intersectional identities one or the other of these may become foreground, and then background, over the course of the lifespan.
What is privilege? Peggy MacIntosh (1990) described it as an “invisible backpack” of safety and positive experiences that is carried by each member of an agent group. It cannot usually be taken off, and it is rarely noticed by the person who carries it. It can disappear; for instance, the person who was previously temporarily able-bodied experiences the loss of that status, and loses the privilege of that status. Rather, for most individuals whose intersectional identities constitute more agent than target groups, privilege is simply how life is, the description of “normal.” In many dominant cultures, the absence of privilege in the lives of target group members is explained as deriving from some real or imagined deficiencies in the target group (e.g., people are poor because they don’t work hard enough), thus justifying the denial of privilege, and implying that privilege might be earned, when such is never the case.
Most individuals have some mixtures of privilege and disadvantage due to the mingling of agent and target group status in their identities. Privilege creates ease, safety, and a sense of clarity (whether false or real) about what is happening in the interpersonal field. Having these can create resilience, or give access to resources that speed the healing process.
Acknowledging privilege is, like acknowledging one’s aversive bias, a process that often initially induces shame and guilt. Like aversive bias, privilege should be an occasion for neither; being born with pale skin or a penis in a culture that values these characteristics and gives privilege to those who have them is an accident of fate and genes that one did not choose. Culturally competent and humble psychotherapists must communicate to themselves that whatever privilege they may have accrued by accident of birth is not their fault, and thus not cause for guilt or shame. It simply is what it is, in the cultural context that ascribes privilege to one’s unearned personal characteristics or life circumstances.
Shame or guilt over privilege, similar to shame about one’s aversive bias, can undermine both effective assessment and treatment in psychotherapy. Most centrally, empathic relating can be undermined when the powerful and sometimes insidious effects of the absence of privilege on well-being and psychological robustness are denied or downplayed; this is one of the ways in which insidious trauma is often missed in diagnostic formulation. A therapist denying privilege can also become numb to the ways in which privilege’s absence shapes life’s realities. To call oneself color-blind is an excellent example of privilege at work; only if the shade of my own skin has not systemically disadvantaged me can I act as if this variable matters little.
Loss of privilege is sometimes a component of trauma. The Syrian physician refugee in the U.S. who cannot pass the language exam to become licensed again to practice medicine, who now drives Lyft for a living, and, as a Muslim and refugee, is a target of systemic Islamophobia and xenophobia, has not just suffered the trauma of war and refugee status; that person has also lost the privileged locations formerly occupied in their homeland. Those losses are a component of the trauma.
When therapists have been able to mindfully and humbly observe their bias and privilege, then they are better equipped to comprehend the complex phenomenon of representation. The 19th Century African American suffrage activist, Anna Julia Cooper, said, “When and where I enter, then and there the whole race enters with me” (quoted in Giddings, 1996). Cooper’s statement is true for each psychotherapist, and each client. When and where we enter the exchange of therapy, into the room come our personal and cultural histories, and our privileges and our biases. We will represent things to our clients, and they to us. This, I would suggest, is more than simply issues of transference or countertransference, as the things we represent, including our status as a trauma survivor or not, are currently active in the social environments in which we and our clients live. The dynamics of representation, even when symbolic, are not simply non-conscious representations of personal history; they are the interpersonal and political realities in which therapy takes place.
Culturally competent and humble practice, with trauma survivors or not, requires a heightened awareness of what it is we represent, and what is represented to us by our clients. This is especially the case when one or the other person represents a component of personal or historical trauma to the other. For cultural competence and humility to be infused into our work, psychotherapists must consider how both visible and invisible aspects of our intersectional identities may carry meanings to which our clients are not insensitive. Therapists may attempt to deny social realities by telling themselves (and sometimes their clients) that they are inattentive to a client’s phenotype, sex, size, or accent; such statements, reflecting experiences of privilege, are experienced as invalidating to clients from target groups, who are rarely perceived, and treated, outside of the framework of those variables.
Privilege, ironically, confers a lack of awareness that one is a representative because an aspect of privilege is that one is not expected to represent one’s entire group. The divorcing heterosexual individual is, for example not seen as evidence of the failure of that sexual orientation, but simply a person having a bad relationship experience. The divorcing lesbian couple may experience more shame for having somehow “proved” the homophobic meme that same-sex relationships are supposedly short and meaningless. For psychotherapists whose primary intersectional identities are those of agent groups, and who are thus most likely to be affected by the non-conscious assumptions of privilege, heightened attention to how and what one represents is essential for culturally competent practice and appropriate humility. This interrogation of one’s identities can also deepen empathy, as the agent group psychotherapist begins to appreciate what it means to live as a visible, audible, or palpable symbol of something good, bad, or indifferent, in one’s daily life.
A basic assumption of culturally competent and humble practice is that we can never assume that clients trust us. This dovetails with what we know about working with trauma. Trauma is itself destructive to trust. When we overtly represent difference in a way that, consciously or not, conveys a message of threat, or if our client evokes the same in us, our willingness to bring these dynamics of difference and representation into shared awareness not only increases cultural competence, but also makes steps toward the deepening of empathy, and makes our humility visible to our client, which in turn is likely to increase our worthiness of their trust.
When we represent current or historical trauma to our clients and are aware of it we increase the possibility of earning trust when we tell the truths about our acceptance of our role as representative of our culture. Acknowledging and validating the presence of dynamics arising from such representations in the therapy office can communicate to clients that we have the humility and willingness to tell truths that are uncomfortable for us as psychotherapists, not simply to invite our clients to experience their own discomfort. Power becomes more balanced when we eschew the anonymity of privilege, and foreground our own identities as our target group clients must do often in their daily lives.
Thus, simply saying, “I’m wondering what it means for our work together that I’m apparently able-bodied and you’re a person with a visible disability” communicates a psychotherapist’s cultural competence and humility in several ways. First, the therapist is being honest about difference and humble about not pretending to know everything that it means. Second, the therapist is taking responsibility for opening the discussion, something that the more powerful person in a dyad rarely does. Finally, the therapist is acknowledging the awareness that s/he represents things to the client. This kind of exchange exemplifies culturally competent practice, which may engender a modicum more of safety for the trauma survivors who now knows that they are not alone with a heightened awareness of the meanings of difference in the room.
Finally, culturally competent practice stands on the foundation of the belief that each human being represents the range of aspects of diversity, and that being culturally competent requires the therapist’s awareness of his own identities and social locations as well as those of clients. Human diversity is not about “special populations,” but about the nature of being human. Challenging oppressive norms is something done not only altruistically, on behalf of traumatized survivors, but also from enlightened self-interest, with the assumption that each person is in some manner harmed by current social structures of hierarchies of value. Using epistemologies of difference which invite the psychotherapist to consider how to think about and analyze experiences of identity are valuable to support cultural competence because the therapist need not acquire discrete data bits about particular group. Rather, the therapist learns how to think about what it might mean to be this living in the client’s intersectionalities of identities.
Experts on the development of cultural competence in psychotherapy have proposed a variety of epistemologies of difference. The one I have found helpful is Pamela Hays’s ADDRESSING model (2016). The acronym stands for a non-exhaustive but relatively complete list of social locations, each of which exists to some degree in all persons, and any of which can become central strands in the development of identities for all individuals; these are:
A: Age-related factors, including chronological age and age cohort
DD: Disability/ability, developmental and acquired, visible and invisible
R: Religion and spirituality
E: Ethnic origins; race/phenotype, culture
S: Social class, current and former
S: Sexual orientation; lesbian, gay, bisexual, heterosexual, questioning
I: Indigenous heritage/colonization history/colonizer history
N: National origin/immigration status/refugee/offspring of immigrants
G: Gender/biological sex (male, female, intersex)/gender identity (masculine, feminine, transgender, cisgender).
This model makes explicit that all humans have multiple identities, while one aspect may become central phenomenologically or foreground interpersonally. Each person is the unique intersection of some combination of these social locations. Identity emerges in the dialectical struggle between individual experiences and temperament, and group and collective experiences and norms. None of these variables will combine in the same manner for any two people, even members of the same family. Root (1998), in a fascinating study of siblings of mixed heritage, found that rarely did two such siblings have the same racial/ethnic identities, nor did such identities reflect obvious phenomena such as phenotypic (aka “racial”) features. Trauma was frequently a variable affecting how people identified. For example, in one family of mixed Euro-American and American Indian heritage in which the Euro-American parent had sexually abused all siblings, all identified as American Indian, consciously choosing to highlight that aspect of identity not associated with the abusive parent. Some of these individuals appeared phenotypically American Indian, but two had blond hair and green eyes like their mother. This family exemplifies in a stark manner the ways in which trauma related to components of identity then shapes the ways in which people will self-identify.
An interesting and valuable exercise that a therapist can do in order to better comprehend the ADDRESSING model and its clinical applications is to create a drawing that represents the various aspects of his identities in which each component of identity is given a size commensurate with its perceived influence on one’s sense of self. These pieces are then arranged in the drawing so that their relationship to one another can be seen. These pictures are tremendously informative; I have seen braids, flowers with petals, Venn diagrams, puzzles, and attempts to represent three-dimensional constructions.
Another interesting experiment that can assist clinicians in comprehending the concepts of multiple and intersecting identities for themselves, which can then improve their capacities to engage in this kind of analysis and awareness with clients, is to do an identity and context informed genogram. In this exercise, I ask people to draw the usual genogram, and then request that they include an ADDRESSING description of each of the people in the genogram. I then request that they draw lines from each of these ADDRESSING variables to historical and contextual factors that influenced these identity components, or were potentially salient to the person because of their identities. So for instance, in the box of a person born in the U.S. in 1926 there might be lines drawn to the Great Depression and WWII. There would also likely be lines drawn to the women’s liberation movement. For a person of Japanese descent, there would be another line drawn to the internment camps; that line also might exist for a person who grew up in an area from which Japanese-American citizens had been deported.
The combination of filling in ADDRESSING variables and cultural/historical/contextual variables on the basic genogram allows certain identity processes to become more transparent, and also begins to explicate cultural and social factors that might have affected those identities. Potentially or known traumagenic social phenomena, and their relationship to identities, can be clearly seen in their relationship to aspects of identity. After doing this exercise, I will sometimes ask people to go back to their identity drawing and add trauma to that picture if they have not already done so, using the trauma and culture informed genogram.
Trauma is another component of identity, weaving into its various strands. Some survivors are also children of trauma survivors, living with legacies of intergenerational transmission of trauma experiences (Danieli, 1998). Still others identify with cultures that have been so immersed in trauma, such as American Indian, African-American, Jewish, Khmer, Native Hawaiian, or Armenian that the experience of historical trauma has been woven into other aspects of identity by the centrality of historical trauma to that social location (Comas-Diaz & Jacobson, 2001, Pole, Gone, & Kulkarni, 2008).
Perpetration is another facet of many people’s identities, variables that fuel some of the shame that leads to denial of bias. Slave-holders, soldiers who shot women and children in wars, or people who imprisoned or tortured others in the countries from which they came all suffered what Shay calls the “moral injury” of being trauma perpetrators. That moral injury was often traumatic to the family cultures that they created, of which both therapists and clients are the inheritors.
Each aspect of intersectional identity in the ADDRESSING model can be linked to the experience of trauma in some manner; this can be due to direct targeting as is the case for hate crimes or gender-based violations, or can have occurred more indirectly (for example, with poverty being a risk factor for exposure to violence). A complete discussion of this topic can be found in Brown (2008). Individuals may also attribute, accurately or not, their experiences of victimization to some component of their identities, and struggle with hatred for an inescapable fact about themselves that they believe rendered them vulnerable.
There are special issues for complex trauma survivors. Because the perpetrators of complex trauma are so frequently those with whom a survivor was or is emotionally intimate, the survivor’s identities may overlap with those of their perpetrators. Struggles with identity, which are commonplace among survivors of complex trauma, may be intensified by the ways in which identification with or loyalty to a group has become contaminated by shared membership with the ones who did harm. Cultural competence can be enhanced by a psychotherapist’s ability to embrace, and invite clients to embrace, these painful contradictions and experiences of betrayal, and to see identity development as reflecting multiple social locations, and as fluid, rather than fixed.
Root, an identity theorist who has used the experiences of people of mixed phenotype (aka racially mixed) to develop her models (1998, 2000, 2004a, 2004b) has argued that, in order to develop an identity theory for persons of mixed social locations, several factors need to be present. First, this model needs to account for within-group bias and oppression, the sort of expression of internalized oppression or horizontal hostility that can occur when target group membership is present.
Second, such a model must see as positive the experience of multiple identities. Root’s model is a useful paradigm for cultural competence in understanding the identity experiences of trauma survivors by construing mixed identities as potentially mentally healthy. Her model next notes the importance of changes in social and political contexts, and social reference groups that are available to a person and which affect their own understanding of identity. Finally, the model must acknowledge the interaction of experiences in the person’s social ecology, including family environment, history, and biological heritage. She portrays her model graphically as a series of nested, interactive, and overlapping boxes in which these various factors are in constant interplay, and in which identity is in a continuous process of development rather than moving toward a fixed and apparently stable state.
Cultural competence and humility in trauma practice is enhanced by this, or similar models of identity formation, because it allows the clinician to conceptualize the client’s identity, not only as a continuously transforming matrix of multiple social locations, but also as not requiring a fixed and stable state in order to be functional. Many survivors of trauma exist in a liminal identity state, one in which transition is a constant. What is less obvious, but equally important for the culturally competent trauma-informed psychotherapist to take into account, is the degree to which liminal identities are those emerging as a function of a post-traumatic healing process, in which identity as a trauma survivor becomes integrated in a positive fashion into other aspects of identity.
Finally, each aspect of identity, each social location informing that identity, and each of the ways in which those variables have become embedded in the experiences of trauma and recovery, are affected by the social and political realities of the world. Cultural competence and humility requires psychotherapists to remain attuned to the ways in which external events, which may seem distal to the therapy process, are proximal in their capacities to evoke affect, intensify bias, or change the meaning of the relationships between people in that process. For a trauma-informed therapist, this should be familiar territory, as this resembles the ways in which events outside of therapy can be trauma triggers. Many therapists reported an uptick in trauma-related materials emerging during the 2016 US presidential race, as levels of microaggressions and actual hate crimes, including several involving the mass murders of members of target groups, has multiplied, with many of those microaggressions being committed by the highest officials of the U.S. government. Taking that into account and dealing with it in treatment has become an important challenge for therapists moving forward, particularly as many therapists report being affected by this uptick in hate speech and hate crimes since November, 2016.
Becoming culturally competent and developing cultural humility as a psychotherapist is a process where one never quite arrives at the conclusion. As one grows in cultural competence, one grows in humility and ignorance, and in the awareness of how one might stretch one’s intellectual, experiential, and emotional edges to better develop empathy with the persons with whom one works. Deepening cultural competence and humility leads one, paradoxically, to make more errors of commission at first. This trend is one that should be familiar to psychotherapists working with trauma survivors; deepening of intimacy and relationship, whether in psychotherapy or elsewhere in life, allows sufficient contact that errors can be made. Aversive biases will express themselves behaviorally, countertransferences evoked by representation will be acted out, and willingness to acknowledge error and listen to distress will be called upon repeatedly. One is never culturally competent; one is always moving towards it, humbly acknowledging one’s need for continuing growth. But like the objects in the mirror, it is closer than we think. The parallel processes and skills inherent in working with trauma serve psychotherapists well on the journey to cultural competence; deepening cultural competence, by deepening humility, in turn, sharpens the skills of the psychotherapist entering the invisible world of trauma.
The final component of this course focuses on the topic of therapist self-care. To thrive as a trauma therapist, and make the investment of time and energy in the process of learning to do this work yield life-long rewards, self-care is not simply a good idea. It’s a necessity.
“To study psychological trauma means bearing witness to horrible events. When the traumatic events are of human design, those who bear witness are caught in the conflict between the victim and the perpetrator. It is morally impossible to remain neutral in this conflict. The bystander is forced to take sides. It is very tempting to take the side of the perpetrator. All the perpetrator asks is that the bystander do nothing. He appeals to the universal desire to see, hear, and speak no evil. The victim, on the other hand, asks the bystander to share the burden or pain. The victim demands action, engagement, and remembering.” (Herman, 1992, p. 8).
Not long after the field of trauma began to emerge in mental health, therapists began to speak with one another of the effects of doing trauma treatment on their own well-being. The concept of “secondary traumatic stress” emerged to describe therapists’ experiences of having referred symptoms from their clients, including intrusive images of materials heard in therapy sessions. The construct of “compassion fatigue” also became part of the vocabulary of trauma therapists. Unlike pure burnout, these experiences seemed unique to the reality of sitting in the presence of the horrors of the world described by trauma survivors. While reducing one’s exposure to this material, similar to reducing exposure directly to trauma, seemed to be an effective step for therapists wanting to reduce such symptoms, they neither allowed for continuing practice with trauma survivors, nor ultimately addressed the deeper transformations affected in psychotherapists by engagement, not simply with the details, but also with the existential disruptions of the world of trauma.
As Herman notes in the quote above, the pull in the trauma dynamic is to become a passive bystander or a perpetrator; becoming engaged as the ally of the traumatized person seems to exact a price, while appearing to do nothing seems easy, and joining with a perpetrator creates the illusion of power. As discussed in the previous segment on countertransference, many therapists working with trauma survivors enter into trauma reenactments with specific clients in which they take on those bystander or perpetrator roles. Even more problematic is when this stance with one client begins to become the therapist’s standpoint in relationship to the world and trauma in general.
Thus, no discussion of doing competent trauma-informed psychotherapy can be complete without a discussion of self-care. It is self-care, and awareness of the ways in which we are affected by working with trauma survivors, that serves as the most effective preventative against falling into bystander and perpetrator roles. Self-care assists the therapist to exit the role of rescuer, which is the other problematic stance of trauma reenactments, and to enter a place of empowerment for self and clients alike. It is also an investment in being able to do this work well for the long haul.
Therapists who work with trauma live in what I have called an “invisible world” (Brown, 2010) where both their clients’ pain and their own empathic and compassionate responses are unseeable and unknowable to those around them. The culture-at-large buries the realities of trauma; a story or two in the news about a combat veteran with PTSD around Memorial Day, or the occasional tabloid presentation about someone’s horrific victimization by a predator, and then silence falls on the topic. Even after the latest mass shooting there are a few days of “thoughts and prayers” and then, for the most part, the world goes silent until the next occurrence. The quotidian nature of trauma is hidden behind these stories; the daily suffering of many is unseen and unheard. The rules of confidentiality, which are in place to protect our clients, also create forms of silence for psychotherapists. Where and how do we speak of our work; we cannot come home and say to a partner, “Oh yes, today I heard about a rape and children being beaten and, oh by the way, that the rapist got off because my client was too terrified to testify.” Many psychotherapists work alone, and even those who do not may not necessarily have colleagues who are trauma-aware and thus both able and willing to hear of the realities of trauma to which the trauma-aware therapist listens. This isolation and absence of social validation, at work and home alike, can compound the challenges of doing trauma work by creating parallel experiences of being invisible and unheard to those of the clients with whom we work.
In the mid 1990s, Pearlman and Saakvitne proposed the construct of Vicarious Traumatization (VT) (1995) to explain the emotional and existential changes faced by many psychotherapists working with trauma survivors. They defined VT as the expectable consequences of engaging empathically with trauma survivors during the course of one’s work as a psychotherapist. They differentiated it from Secondary Traumatic Stress, as well as from burnout, proposing instead a framework for comprehending the deeper effects to which long-term work with trauma survivors leads.
VT, unlike STS, does not entail having PTSD-like symptoms arising from exposure to information from clients about their Criterion A traumatic stressors. Unlike burnout or compassion fatigue, VT does not reflect general stressors in the workplace; in fact, the authors who first described it were part of a trauma-aware, compassionate, collegial workplace that was under the direction of one of them. VT is not about having no control over our work.
VT is, rather, unavoidable, and when understood and dealt with head-on, not problematic; in fact, it has the capacity, when used well, to enhance a trauma-informed psychotherapist’s capacities and to lead to post-traumatic growth for the therapist. Understanding and engaging with one’s own VT is core to self-care for a trauma therapist. Self-care is an ethical necessity for continuing work in this field.
VT is also not the same as countertransference, although it inhabits a similar emotional territory. Pearlman and Saakvitne arrived at the construct through their attempts to explicate the countertransferential experiences that they and the therapists they worked with encountered in working with trauma survivors, particularly those with complex trauma. As noted in the previous section of this course, countertransference can be extremely powerful in working with trauma survivors because of the intensity of painful emotions that emerge in the work of psychotherapy with this population (Dalenberg, 2000). Countertransference, however, occurs in a specific therapeutic relationship and responds to the particular variables present in the unique encounter between a given therapist and individual client or family.
VT is a more profound, far-reaching, and extensive experience than is countertransference, secondary traumatic stress, or compassion fatigue. It reflects the trauma therapist’s journey with his clients into that invisible world and becoming a citizen of that planet. It is not simply about a specific client-therapist relationship, but rather the cumulative impact on a psychotherapist of that person’s engagement with, and both conscious and non-conscious responses to, the stories and feelings of many trauma survivors.
It also involves the ways in which those stories intersect with the therapist’s own experiences of trauma. Many therapists are themselves “wounded healers;” many therapists working with trauma have chosen this field, consciously or not, because of their personal or cultural trauma histories. VT is not, however, the province only of wounded healers; acknowledging one’s own status as wounded rather than attempting to avoid or deny it will assist a therapist in coming to terms with VT, while VT may be more shocking for therapists whose trauma work becomes their own just world trauma.
Psychotherapists’ VT comes with them to every encounter in life, not only those in the therapy office, and is powerful in large part because its effects cannot be compartmentalized within the confines of professional life. VT is the story of how being a trauma therapist changes us. With self-care, it is the story of how we are changed for the better. “There is a crack in everything – that’s how the light gets in” sings the poet Leonard Cohen; approaching those cracks in our own hearts with compassion and self-care does make them conduits for light, not simply places where we or our clients have been broken.
VT develops in almost every psychotherapist who works consistently and intentionally with trauma survivors because these stories of harm and betrayal not only evoke emotions related to a psychotherapist’s own identities and life experiences, and resonate to our own trauma stories. It also occurs because our experience of witnessing these lives acts on and changes our identities and their meanings forever. VT creates a profound transformation in the psychotherapist’s own consciousness and sense of self as an actor in the world. In that transformative process, through the experience of genuine, open-hearted emotional encounter with our clients who have survived trauma, we experience a change of world-view, identity and self-view, and find ourselves reevaluating our needs, feelings, and interpersonal relationships. As Pearlman and Saakvitne write, “…we view it [VT] as an occupational hazard, an inevitable effect of trauma work.” (1995, p. 31).
I would add that encountering VT is a spiritual/existential challenge to therapists who work with trauma. If we rise to and meet that challenge, we grow. Failing to do so, we become distant, disengaged, and emotionally hardened, risking our capacities for ethical and competent work practice.
VT is not a passing experience. If a psychotherapist stays engaged in work with trauma survivors then VT becomes another component of self. This is not necessarily a bad thing; in fact, when VT is acknowledged and embraced, and integrated into a psychotherapist’s sense of self rather than denied and disowned, it becomes a source of resilience and an inner place from which a psychotherapist can join empathically with trauma survivors in ever more profound ways. If I can become aware of and know how simply witnessing stories of trauma affects me, I have an experiential base that allows me to validate the transformational power of direct trauma exposure in an emotionally truthful manner. My VT, for example, informed my responses to survivors of torture, war, and unexploded ordnance who I met on a trip to SE Asia toward the end of 2016; I was able to be with them empathically, not avoid them or objectify them. It also informed my decision about how and when to retire from direct service as a psychotherapist to trauma survivors; I was able to assess that I was coming close to having an “empty tank” within the next few years, and decided to retire before I began running on empty, a state in which many therapists, at the ends of our careers, undo the relational healing we have offered previously.
When my clients hear and feel my responses to their stories, they can hear and feel a resonance that has its roots in VT. Recalling the earlier segment discussing the application of empirically supported relationship variables to work with trauma survivors, VT can become a component of more authenticity and authentic empathy for therapists. Looking at VT from this perspective makes it an avenue for the therapist’s own posttraumatic growth, a process of transcendence and increased personal wholeness that emerges from the encounter with the emotional abyss (Tedeschi & Calhoun, 2004). Dealing with VT enhances a therapist’s capacity to maintain emotional competence (Pope & Brown, 1996, Pope, Sonne, & Greene, 2006, Pope & Vazquez, 2010), which supports ethical practice.
Because it can enhance empathy and the capacity for genuine connection between psychotherapists and trauma survivor client, VT can also become a catalyst for enhanced cultural competence and humility in therapists. This is because, in my experience, the heightened capacities for empathy engendered by successful integration of the VT experience make psychotherapists more attuned to possible ruptures in the relational field, and thus more willing to have the humility to notice where they may be acting in a culturally other-than-sensitive manner with clients. Just as, for many trauma survivors, the experience of trauma has given them the coping strategy of heightened awareness of other humans’ subtle emotional cues, so too can VT be a path toward a more nuanced awareness by therapists of where meaning lies for our clients and how to best be fully present in our relationships with them. This sort of deepening of awareness and connection is foundational to an approach to trauma-informed psychotherapy that goes beyond an intellectual grasp of the value of greater sensitivity to trauma to an embodied, felt, and committed relationship with that sensitivity.
Left unaddressed, however, VT has the potential to undermine a psychotherapist’s capacities because of its deadening effects on a psychotherapist’s relational and empathic capacities. The risks inherent in VT are similar to those arising from direct trauma exposure. Psychotherapists who cannot identify or acknowledge their VT may find themselves becoming numbed and distancing from the stories that they hear. They may begin to use a variety of affect-control strategies, such as over-work, substance abuse, or intellectualization, to contain the distress that is an inevitable and normal human response to the work of listening to trauma stories. The us/them split in the field of trauma practice, in which trauma survivors become the disturbed “other” from whom professionals create emotional and cognitive distancing reflects a profession-wide failure to adequately acknowledge and metabolize our collective VT. The more I need to assert how I am not “one of them,” and the more exotic and different I make the narrative of post-traumatic distress, the more likely it is that I will lose attunement to clients, ignore or minimize their experiences of pain, and be adversely affected by my own VT.
VT occurs in part because of what psychotherapists working with trauma survivors witness in our work. Even if a psychotherapist were to restrict himself only to seeing those trauma survivors who have experienced natural disasters, that psychotherapist would still be a witness to knowledge of extreme human suffering, loss and grief, and to the knowledge that life as one knows it can be swept away in an instant, irretrievable. There is simply not a trauma known to humankind the realities of which are not threatening to our illusions about the safety and stability of the world.
Psychotherapists who work with the survivors of interpersonal trauma, combat, genocide, and discrimination will have, in addition to confrontations with the random and chaotic nature of the world, emotionally intimate encounters with the realities of human cruelty. As a specialist in therapy with survivors of childhood maltreatment, I know that during my four decades of psychotherapy practice I sometimes felt as if I was surrounded by evidence of unspeakably horrible things that adults have done to children, behaviors beyond my capacity to have ever imagined until my clients gave me this painful education. It is impossible to work with trauma survivors and remain in a state of naive hopefulness about the world and its human inhabitants. But naive is the important word.
This is because we must be hopeful as trauma-informed psychotherapists. Hope is a necessary ingredient of therapy, something we both know intuitively and can demonstrate empirically (Snyder, Michael & Cheavens, 1999). The trauma psychotherapist’s non-naive, grounded hope for the client’s healing process and her expectation that what is offered will be of assistance to the survivor are essential ingredients of what we do for the people with whom we work. Ironically, some of the same experience as a psychotherapist that gives one hope, the pleasures of having had the time to watch many people heal from trauma, also exposes psychotherapists to increased realities of VT as we spend more time in the presence of survivors.
Because VT is a profound and sometimes hidden experience for trauma psychotherapists, it touches on all aspects of the psychotherapist’s multiple identities and may aggravate a therapist’s hidden wounds of insidious trauma, betrayal, or cultural experiences of danger. Knowing the meanings of our own intersectional identities as they create both vulnerability and resilience allows us, as psychotherapists, to more accurately understand what VT is acting on, and how it is likely to manifest.
Although VT involves a transformation of the self of the psychotherapist at a deep level, the signals to us that we are experiencing unaddressed VT commonly emerge behaviorally and interpersonally, both with our clients and with our emotional and social networks of support. VT is not the problem; failing to acknowledge and address it is. Saakvitne, Gamble, Pearlman, and Lev (2000) have identified a variety of signs and symptoms that are common in psychotherapists experiencing VT. These include emotional numbing and withdrawal, feelings of hopelessness and despair, loss of meaning-making and spiritual connection, loss of respect for survivors and one’s own profession, and distancing from intimate relationships. Persons experiencing VT also note that they feel engulfed by their work and unable to escape from it. Feelings of loss of safety and loss of the just world figure heavily in VT for some psychotherapists, while others may experience a lighting up of previously quiescent insidious traumatization.
I have found it helpful to use the following checklist of common signs of VT to assess one’s own VT load. Take a minute to see where you score on this list. Give an item 0 points if you never feel it; 1 point if seldom, 2 if occasionally, 3 if frequently, 4 if always.
VT Symptom Checklist
|Feelings of alienation from those around you|
|Inability to play or take down time|
|Dreading going to work or volunteer setting|
|Problems with respecting your own boundaries|
More fear for safety of loved ones
|More fear for own safety|
|No “me” time|
|Talking about trauma work all the time|
|Feeling disconnected from friends and family|
|Feeling invisible outside of work|
|Less enjoyment of sex|
|Loss of respect for victim/survivors|
|Feelings of hopelessness|
|Feelings of despair|
|Emotional Numbing-“hardened heart”|
When you have tallied up your score, you have a reasonably good indication of your VT load. More symptoms and more scores of 3 or 4 are warning signs that you not only are experiencing VT – you’re not dealing with it.
Because VT, like trauma itself, does not happen to a generic psychotherapist, issues of a therapist’s identities all play out in how VT is experienced and expressed, and in the strategies available to her to respond to and integrate VT. When specific interventions have been designed to address VT, such as the Risking Connection curriculum, outcome data tend to indicate that the emphasis on psychotherapists’ own self-care in the training seems to be a central aspect of its effectiveness.
This message about self-care is central for continuing competent practice of trauma-informed psychotherapy. Self-care is countercultural for many of the larger cultures informing a psychotherapist’s identities. The social constructions of our identities frequently contain prohibitions on care for self, on seeking support, or on using scarce resources if we are not in dire need. It can, consequently, be useful for psychotherapists who are struggling to master self-care to frame it in terms of ethics and competence.
Maintaining competence is a core component of ethical practice; for psychologists it is written specifically into the APA Ethical Principles and Code of Conduct (APA, 2002). While generally competence has been defined in terms of acquisition of knowledge and supervised experience, Ken Pope and I (Pope & Brown, 1996) proposed the concept of “emotional competence” when discussing work with sexual abuse survivors as an additional necessary facet of competence, and thus ethical practice, for psychotherapists working with trauma survivors.
This construct contains several variables, including the capacity to hold the ambiguity of clients’ remembering processes, and the ability to remain fully emotionally present with the painful details and strong affects of a survivor’s story. I would now add to that construct that emotional competence includes the capacity to mindfully and compassionately observe one’s own responses to that story, including one’s VT dynamics, and to mindfully and compassionately observe one’s own transformations in the wake of continuing engagement with trauma survivors.
In order to achieve these goals of emotional competence, self-care becomes not an option, but rather as much a necessity as the acquisition of up-to-date knowledge of new therapeutic techniques. That said, self-care is a highly personalized thing. The shapes it takes must be those reflecting the individual therapist’s preferences and capacities. However, there are variables that ought to be present in self-care, no matter what shape it takes.
Self-care should engender hope and undermine despair. The “trance of despair,” as I have previously referred to it (Brown, 2010), is one of the symptoms of VT gone untended; it is the problematic transformation of self, arising from becoming emotionally flooded by empathic connection with trauma survivors’ despair and hopelessness. Thus, self-care activities should leave the therapist more hopeful and optimistic about the world, her/himself, and her or his work.
Self-care should assist the therapist in dealing with her or his existential challenges and fears. As Yalom (1980) noted in his foundational work on existential psychotherapy, existential crises are precipitated for us by encounters with the four “existential psychodynamics” – death, freedom, isolation, and meaninglessness. Trauma-informed therapy means that the therapist will daily encounter these topics in the starkness of their realities. Self-care assists the therapist with integrating these realities into consciousness without becoming trapped in feelings of hopelessness and helplessness. Rather, the converse occurs, even in the presence of knowledge of terrible realities.
Self-care should also lead to joy, or at least its possibility. It should evoke the “homo ludens,” the playful self. It should provide connection and assist the therapist in reducing isolation and invisibility. Self-care is likely to be more effective if some of it allows the therapist to be more fully embodied, as one of the pernicious signs of VT is increasing dissociation from the therapist’s own body, something that appears to be aggravated when the therapist came into trauma work already struggling with embodiment.
How a therapist constructs self-care to include these ingredients will be variable. While the norm in our profession is to suggest personal psychotherapy and consultation, these are neither the quintessence of self-care, nor the end-all and be-all of this activity. They are, for instance, unlikely to contain the elements of playfulness and embodiment that are central to a well-developed strategy for self-care. But neither can belly-dancing, gardening, or raising chickens substitute for some kind of focused and intentional interaction with colleagues, both peers and elders, about the nature of this work; personal consultation at the very least is necessary. In this age of on-line video calling, a face-to-face consultation does not require a community of colleagues who live in physical proximity; geographic isolation no longer necessarily creates interpersonal isolation.
Trauma-aware therapists must be alert to their own self-talk about self-care, and the ways in which they sacrifice care for self in order to offer care to others; canceling one’s self-care activity to fit in a client in crisis may be fine once, but when it becomes a pattern, a therapist may be flirting with allowing VT to go unaddressed. Dealing with our vicarious traumatization is a non-optional, central component to the emotional competence required for working with trauma survivors.
We also need to know how to recognize when we are approaching the end of our capacities to do this work. Assessing our levels of VT, our own numbness or distancing responses, or our own persistent arousal, and seeing these behaviors and/or feelings not responding to our usual shorter-term self-care activities, allows us to decide to take extended time off, in the form of a sabbatical, or to retire. Being a psychotherapist is not a life sentence; while it is challenging for trauma therapists to leave their work, it is essential to know when to say “when.”
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