Trauma

A Practitioner's Guide to Counselling

Thom Spiers, Thom Spiers

• Publisher: Routledge
• Year: 2018
• ISBN:
  9781317798286
• Edition: 1
• Topic: Psychology
• Subtopic: Applied Psychology
• Index: Psychology

In recent years a number of high-profile disasters have heightened public awareness of the impact of trauma. This book offers a comprehensive guide to all aspects of trauma counselling, covering:
* trauma assessment
* resourcing the trauma client
* trauma aftercare
* working with trauma in private practice
* trauma and the therapist
* a brief history of trauma.
This practical and effective guide to trauma counselling will be invaluable to counsellors, GPs, social workers, human resource managers, emergency response organisations and all those involved in treating trauma victims using counselling skills.

Chapter 1
An integrated treatment model

Thom Spiers

At the heart of this book lies a desire to treat people first and foremost as human beings. This may seem an unusual place to begin, as the assumption may be that this position is taken for granted by most counsellors. However, increasingly the work of counselling is pressed to follow a predetermined course. Commercial and social pressures encourage counsellors to produce a result measured by our ability to rid people of symptoms or to facilitate change. Little value is now given to what may be profitable or transformational in the unfolding of a person’s adversity or the counsellor’s ability to stay close to the client during this process. The ability to quantify how and why distress sometimes disappears is invaluable and undoubtedly the desire to alleviate distress is a worthy one. But the ability to work with those in distress simply on the basis of their humanity and not because of an anticipated outcome infuses counselling with a palpably different quality.

If we worked simply from a place of symptom removal we would have to concede that at times we could not achieve our goal. As Victor Frankl (1959: 156) says, with some conditions such as schizophrenia our work might be considered pointless. Perhaps from a political perspective we might even begin to question the value of having such people around in society at all, since they cannot be ‘put right’. However, as Frankl gently explains, we work to heal the hurts in others and ourselves in the belief that whilst people may lose their functionality they can never lose their humanity. It is this attitude which is so important as we work with traumatised people. Trauma counselling in particular is awash with techniques which seek to prevent, reduce, manage and cure the symptoms of trauma. The current emphasis on these procedures is so great that the client can easily become an object that is dealt with rather than a person who is met with. The need to refocus on the person cannot be emphasised enough (Johansen and Kurtz 1991: 62).

Working with people who have been traumatised is a work of integrity. It is essentially about restoring wholeness to individuals whose trusting relationship with the world has been betrayed by nature or circumstance. Rebuilding trust can only take place when the counsellor and the client build a strong-enough alliance to enable the client to move from reticence to boldness in the exploration of his¹ traumatic experience. This includes perhaps an examination of those actions and reactions he finds unacceptable in himself.

This chapter is an exploration of trauma as an issue, and some of the ways to work with it. It draws on the accumulated wisdom of many schools of counselling and is a synthesis of ideas, methods and techniques that have illuminated work with those who have been traumatised. This however is only part of the story. Explaining the way this work is accomplished does not illustrate how it unfolds in a relationship. To capture this it is important to set this integrated model amidst broader principles of how we relate to each other as people. This is why we begin with the humanistic influence on our work.

The humanistic contribution

The way of working presented here rests in the humanistic tradition. So, primarily, it is concerned with what people are actually experiencing in response to traumatic situations and how they are coping with this, rather than enquiring ‘why’ they are feeling this way. Whilst there is some consideration of predisposition and vulnerability to trauma it is more concerned with those who have had a reaction, what form this takes, the purpose this response serves, and most of all how best the person in distress can be helped.

The humanistic tradition emphasises our relationship to the world in which we live. It recognises that human survival whilst instinctual, is not inevitable, and depends on relating to what is sometimes a hostile environment. Thus what is understood as problematic or symptomatic can be understood as a ‘creative adjustment’ to an often antagonistic world. Post-traumatic reactions are therefore seen as self-supporting, and evidence of humanity not pathology. This then prompts consideration of diagnosis from a humanistic perspective. Although this model draws on a helpful psychiatric description of post-traumatic symptoms, it seeks to emphasise the unique experience of each individual. People’s reactions to trauma may contain common elements but their recovery will depend on the development of a treatment which meets their singular needs. From a standpoint which sees post-traumatic reactions as usual, this model runs contrary to some orthodox psychiatric views that would assert judgementally that such reactions are a ‘decompensation’ a jargon term, meaning ‘failure to generate effective psychological coping mechanisms in response to stress, resulting in personality disturbance’ (New Oxford Dictionary, 1998).

Humanistically, post-traumatic reactions are seen as part of a process towards health and recovery. Even where these symptoms appear to persist beyond their usefulness they are understood to be self-supporting strategies. The symptoms themselves serve a healthy function but are problematic in that they are an habitual and ongoing response to new, non-threatening situations.

From a humanistic perspective each person is seen to make his or her own bargain with life. Trauma forces people to cut a new deal for themselves and this involves choice and responsibility. Decisions about the individual meaning and personal relevance of an experience are therefore central in trauma recovery.

This model derives from humanistic practice a desire to create a more egalitarian therapeutic relationship. Trauma impacts significantly on a person’s sense of power and control over the world and so restoring a connection with his personal authority is an essential part of recovery. This restoration is accomplished in the way the counselling relationship is conducted and flows naturally from the philosophy, which guides it.

This helping model rests on the belief that when counselling takes place there are simply two people meeting, one called counsellor and the other client. These names are helpful for both. For the client they provide assurance that they are in the presence of a compassionate witness to their experience who has expertise in working with those in distress. For the counsellor they are a reminder of professional obligations to the client who is in his or her care. The time spent meeting is thus designed to honour the client’s need for safety and for the counsellor to remain open to learning from this particular client. Out of this relationship will come healing. The techniques discussed in this book, although powerful, are only useful in the context of a relationship in which trust allows people to abandon self-protection and re-experience their psychological pain in safety.

The task of counselling in humanistic terms is conceived of as a process of reintegration where people have become aware of a fundamental split in their self-concept (Spinelli 1994: 13). This notion of fractured self-concept plays an important part in trauma counselling (particularly where people believe they should have been able to deal with experiences more competently or should feel differently about their experience). This returns us to our starting point: treating people in their entirety as human beings. Trauma counselling is therefore about the client achieving the self-acceptance that comes out of a validating and congruent relationship and not only about removal of symptoms through treatments applied by the counsellor.

Although humanistic philosophy determines how this model is practised it does not claim a unique understanding of trauma. It is merely one indispensable contribution to our understanding of trauma treatment. The model suggested here is a combination of the insights proffered by several systems of psychotherapy. Most counsellors will find some common ground with the theoretical construction offered. At the very least they may find processes they know well called by different names; at best they will enrich their understanding of trauma work through the deeper insight provided by considering the valuable perspectives held by various schools of thought.

The psychoanalytic contribution

Love him or hate him, Sigmund Freud is the grandfather theoretician of counselling and psychotherapy. Indeed love and loathing pursued Freud throughout his life, and the understanding of humankind he bequeathed is perhaps a testament to this. Freud’s journey of understanding led him to encounter women in great distress. He discovered through hypnosis that often the source of their disturbance was early traumatic experience often related to childhood sexual abuse (Herman 1992: 13). These women had ‘erased’ the experience from their conscious mind so that ordinarily these memories were inaccessible to them.

From this knowledge Freud hypothesised that the mind had a three-part structure. A conscious part made up of thoughts and feelings of which we are currently aware, a preconscious part containing thoughts, feelings and memories we can easily recall, and an unconscious part containing experiences too painful to recall (Hall 1979: 54). From his work with ‘hysteric’ patients Freud postulated that premature exposure to sexual experience had overwhelmed their conscious mind resulting somehow in an active covering over of the experience which was then ‘forgotten’. This process he named repression. Significantly Freud saw that the unconscious remained an active influence in everyday life. The memory of these experiences was buried in the unconscious but buried, as it were, still very much alive. As Freud and his peers pursued the aetiology of hysteria, those afflicted found that in telling the story of their abuse and having their agony recognised their psychological torment ended (Freud 1964: 173).

Over many years, as his thinking became increasingly focused on intra-psychic conflict, Freud abandoned the reality of sexual abuse in people’s experience, replacing it with a notion of fantasised incestuous relationships (Herman 1992: 14). He added to the contents of the unconscious, unsavoury instincts and destructive impulses that, along with traumatic experiences (because of their menacing potential), had to be repressed. Whilst the reasons for this shift in emphasis were regrettable and in some cases had grievous consequences for those abused, the healing effect of the investigative relationship born of Freud’s work was powerful. From this developed the talking cures widely practised nowadays.

From this brief synopsis of Freud’s work we can review the valuable contributions he made to our understanding of trauma. Firstly though, we have to turn the psychoanalytic process on its head. Comprehending adult suffering by fathoming the depths of the unconscious to uncover those crises, real or imagined, which organise current behaviour is the stock in trade of most developmental-based psychotherapies. However, in trauma counselling, by studying blows to the adult psyche we can perhaps gain insight into how the patterns of survival which are called neurosis or pathology actually form in childhood (Lifton 1993: 12).

Dissociation and mechanisms of defence

Psychoanalysis has given us an understanding of the human mind’s capacity to disintegrate in the face of great danger. Our ability to separate from experience is a final life-preserving mechanism when our usual responses to danger, fight or flight, are to no avail. With our defences in disarray, confounded by the magnitude of what we are facing, dissociation works to diminish the intensity of what we are experiencing (Sainsbury 1986: 60). There is a momentary breach in the continuity of the self as the stricken individual contracts away from the trauma. The experience is left, incomprehensible, unfelt, numbed out, forgotten and, crucially, dis-integrated! Here it may remain, out of awareness yet exerting a limiting influence on potential, perhaps waiting like a behemoth to be reawakened by subsequent traumatic incidents.

Unfortunately dissociation, although a sophisticated defensive procedure, is undiscriminating. Once applied it blunts the individual’s whole emotional acuity. The psychoanalytic school puts forward this conceptual view to explain those symptoms of trauma which include reduction of emotional response, detachment from others, etc. (See Chapter 2 for a fuller description of this.)

Psychoanalysis furnishes us with rich insights into how the psyche defends itself against inner and outer conflicts. It can be argued that the many mechanisms of defence so discretely named by Freudians are in fact elaborations on a theme, with dissociation and repression at their core. They are essentially about ‘feeling and not feeling’ in relation to a traumatic event (Jacobs 1988: 81).

The clearest example of this is denial. Denial put simply is the individual’s refusal to accept an ‘unwelcome or unpleasant reality’ (Sandler 1985: 333). It is a way of repudiating the thoughts, feelings or sensations that would be overpowering if a person were to accept the actual enormity of a situation. So just as someone may deny the meaning of their loss following the death of a loved one, in the wake of traumatic incidents individuals may protect themselves by denying the importance or significance of the experience. They may report that they are unaffected: ‘I don’t feel anything’ or ‘You just have to get back on the horse/bike/front of the train’, or whatever. Of course this may well be the person’s genuine feeling but equally it may be a self-protective reaction, a conscious suppression or unconscious repression of responses. Denial usually occurs to prevent expression of specific feelings such as sadness, anger or guilt, which if admitted create a conflict in the person’s perception of who he is (‘self-concept’). It is therefore important that the counsellor holds an awareness of which feelings are not present when meeting with a client and to gently acknowledge these. Although the client may not be amenable to counselling at this point, embracing the potential of what could be present conveys a message to the unconscious that many reactions are possible and permissible. The client may then return at a later date if the self-help of denial becomes weary or is fractured by another trauma, safe in the knowledge that he is accepted no matter what the symptom is.

In the past, social and cultural pressures have supported the use of denial. Nowadays, whilst people may be more prepared to talk about the impact of events, they remain unwilling to speak about not managing this impact.

Danny was a bus driver. He came to counselling after a tourist had stepped out in front of his bus and was badly injured. Danny explained that there was nothing wrong with him and that his manager just wanted him ‘to get checked out’. The counsellor noted that Danny’s initial conversation was quite flat. He asked if Danny had any thoughts or feelings about the incident. ‘No!’ he replied sharply. ‘It’s not my fault these bloody tourists are always walking out, it’s his own stupid fault he got hit, nothing to do with me.’ His counsellor responded, ‘So not even a little bit angry or … Danny interrupted, ‘No, I’m fine honest, thanks!’

The way in which psychoanalytic theory has developed, moving ostensibly away from external trauma and into exploration of conflicts which emerge within the self, has enabled us to acquire knowledge of the complexity of the human mind and its versatility in finding a range of ways in which dissociation can be expressed.

It is thus crucial that the trauma counsellor gains familiarity with mechanisms of defence including, splitting, projection, fixation and regression, since these are naturally present in all life-threatening experiences. It is important for the counsellor to know if and when the client has perhaps introjected elements of the traumatic experience or notice when the client’s feelings about the traumatic event are displaced into other settings. This reflection provides valuable information about the nature of the individual’s reaction and guidance as to which interventions may be helpful.

The therapeutic relationship

Psychoanalysis as it was formulated recognised something significant about the relationship between counsellor and client. Motivated to understand the erotic and dependent feelings his patients developed whilst being treated, Freud’s work led to the emergence of the concept of transference. In the classic sense this came to refer to the perceptions and expectations that the client brought to the counselling relationship (Khan 1991: 25). Depending on their previous experience of relationships in particular familial relationships, patients would approach the therapy relationship with hopeful anticipation or desperate apprehension and much in between. Past experience, good and bad, was literally transferred to the present. Similarly, although initially considered to be the counsellor’s reaction to the client’s ‘material’ it was later acknowledged in the concept of countertransference that counsellors too came with their own history and possessed their own hopes and fears about relationships. So now a broader view of transference and countertransference refers to all feelings experienced in the counsellor-client relationship.

The benefit of such an understanding of relationships is immeasurable. Take for example a traumatised person who comes with a generalised expectation of being blamed. This is likely to influence his involvement in the counselling process, perhaps experiencing the counsellor’s request to retell details of the incident as inquisitorial, searching for their culpability rather than a supportive exploration of ...

Table of contents

• Cover
• Dedication
• Title
• Copyright
• Contents
• Illustrations
• Acknowledgements
• Contributors’ Acknowledgements
• Introduction
• 1 An integrated treatment model
• 2 Trauma assessment
• 3 Resourcing the trauma client
• 4 Trauma aftercare: A four-stage model
• 5 Working with trauma in private practice
• 6 Trauma and spirituality
• 7 Trauma and the therapist
• 8 A brief history of trauma
• Appendix 1
• Appendix 2
• Bibliography
• Index