Safety and a Security in Trauma Treatment
By Gregory Hasek MA/MFT LPC
I will be writing a series of articles on working with clients who present with possible abortion related trauma in their past. The intention of this article is to begin a framework of how to professionally treat abortion related trauma, and the steps to take using evidenced based practice and sound psychological theory. The articles will be an integration of the knowledge I have gained over the years in working with clients who present with trauma, combined with the knowledge of theorists who have written about it in their own work with clients.
It is unlikely that a client will walk through your door and report a presenting problem of abortion related trauma in their past. There are many reasons for this. They include: cultural conditioning, use of defense mechanisms, behavioral conditioning, gender roles, fear of a tapping into too much pain, fear of the unknown, lack of trust in the therapist, political influence, religious beliefs, preexisting trauma's effect on the ability to "feel" the effect, feminist influence, unresolved trauma between genders, etc. As you can see, there are almost too many reasons to name why a client, who may have experienced abortion related trauma, would not report it as a presenting problem. Most likely, they will present with a behavioral manifestation of a trauma in their past, and it's possible that abortion may be one of those traumas. For the sake of this article, I will use the example of a client as a married couple who does have a abortion decision in their past but their presenting problem is marital conflict and the husband's use of pornography.
The first thing I think about when a couple like this comes into my office is the need to create place of safety for both of my clients in the couple system. The last thing I want to happen is that the counseling room becomes a place of pain versus healing. If that happens, then we as therapists are providing nothing different than what they already experience at home. As a therapist who works with trauma, I need to be thinking that the client's limbic system may be in a state of activation, so the likelihood of escalation in sharing their story is quite high. In this scenario it is very common for the wife to be experiencing some PTSD symptoms just from the disclosure or as a result of finding her husband viewing pornography. The tendency is to lean toward being too empathetic to the wife who has just experienced trauma and forget to show empathy to the male client that is also experiencing trauma. The male's trauma is often from being caught or being asked to make a disclosure, not knowing if that disclosure could risk his marriage. This is important for me to remember or I could lose the trust of the husband in our future work. It is important to remember that he has a "story", and that story is often full of shame. I need to be thinking about how to respond to him by not creating more shame, despite feeling the tug emotionally and sometimes codependently from the wife to align with her. I especially need to be aware that the wife in this scenario may be coming in with a lack of trust in me as a male therapist because of what she has experienced.
Second, I need to provide a "secure base". I need to provide for my clients what a securely attached parent would provide for a child who was anxious and crying. This may include: mirroring, validating and empathy for each client. Harville Hendrix (2007) describes these three elements of attunement as the "Couple's Dialogue". I also want to provide what Carl Rogers (1980) calls "core conditions" in counseling. They are empathy, congruence and unconditional positive regard. I also want to be balanced in my interactions with both clients, and be systemically attuned to not internally labeling one client as the identified problem. I am also assessing their attachment styles and wondering how they are being triggered in those styles. I know from experience that under stress, these attachment styles and the emotions and behaviors that go with them, tend to get put into motion. I am also assessing and wondering about each client's ability to regulate and self sooth their emotions as they sit in front of me. I am aware of the pace of the session and cautious of either client being triggered in their fight or flight response. If I see this, I need to be able to help bring the intensity down, and possibly open the counseling door and allow clients some space if needed to walk and take a break. This tends to help the body not feel trapped. It only works though if both clients know ahead of time, that their partner is not leaving or "abandoning them" in the session.
Finally, I want to watch and assess for the couple's interactive pattern. I want to see how the couple interacts, how they communicate. As I assess, I am wondering if their style of communication is breeding more trauma in their relationship. In my experience of working with couples that come into counseling with these type of presenting issues, this is often the case. There is likely a long history of traumatic interactions that have either been fueled by trauma they have either experienced in the past together, or as individuals. That past trauma then gets triggered in the current relationship. I can then begin using some of the techniques learned from Emotionally Focused Therapy. Emotionally Focused Therapy is an evidenced based practice model used in working with couples. Susan Johnson developed this model. Johnson (2005) suggests a stage approach in working with couples who present with trauma and the resulting negative interactive cycle. The first stage includes: assessment, identify the negative cycle, assess underlying attachment emotions, and frame the problems based on the cycle, the attachment needs and fears. As I assess and identify the negative cycle of interaction that is before me, I can begin to reframe some of the deeper level emotions with my clients. All along, I am keeping the goals of Emotionally Focused Therapy at the back of my mind. These goals include: to expand and reorganize key emotional responses, create a shift in partner's interactional positions and initiate new cycles of interaction through corrective emotional experiences and lastly to foster the creation of a secure bond between partners.
Johnson (2005) authored a book called, Emotionally Focused Couple Therapy with Trauma Survivors. In that book she evokes the image of the dragon as a metaphor in describing the power of trauma and its ability to breathe fire into the lives of survivors and their partners. She goes on to say that the dragon's fire is the helplessness, isolation and betrayal that are at the core of most traumatic experiences. She suggests the power of a secure attachment can be the antidote to the effects of the fire.
As you can see, our work as therapists can be taxing and require a lot of emotional energy. Trauma work is also slow process and requires therapists to be mindful of each step of the way. When we help clients begin to "slay the dragon", we are reminded of the important and rewarding work we do.
References
Hendrix, H. (2007). Getting the love you want. New York, NY: Henry Holt and Company.
Johnson, S. (2005). Emotionally focused couple therapy with trauma survivors: Strengthening attachment bonds. New York, NY: Guilford Publications.
Rogers, C. (1980). Way of being. Boston: Houghton Mifflin.
By Gregory Hasek MA/MFT LPC
I will be writing a series of articles on working with clients who present with possible abortion related trauma in their past. The intention of this article is to begin a framework of how to professionally treat abortion related trauma, and the steps to take using evidenced based practice and sound psychological theory. The articles will be an integration of the knowledge I have gained over the years in working with clients who present with trauma, combined with the knowledge of theorists who have written about it in their own work with clients.
It is unlikely that a client will walk through your door and report a presenting problem of abortion related trauma in their past. There are many reasons for this. They include: cultural conditioning, use of defense mechanisms, behavioral conditioning, gender roles, fear of a tapping into too much pain, fear of the unknown, lack of trust in the therapist, political influence, religious beliefs, preexisting trauma's effect on the ability to "feel" the effect, feminist influence, unresolved trauma between genders, etc. As you can see, there are almost too many reasons to name why a client, who may have experienced abortion related trauma, would not report it as a presenting problem. Most likely, they will present with a behavioral manifestation of a trauma in their past, and it's possible that abortion may be one of those traumas. For the sake of this article, I will use the example of a client as a married couple who does have a abortion decision in their past but their presenting problem is marital conflict and the husband's use of pornography.
The first thing I think about when a couple like this comes into my office is the need to create place of safety for both of my clients in the couple system. The last thing I want to happen is that the counseling room becomes a place of pain versus healing. If that happens, then we as therapists are providing nothing different than what they already experience at home. As a therapist who works with trauma, I need to be thinking that the client's limbic system may be in a state of activation, so the likelihood of escalation in sharing their story is quite high. In this scenario it is very common for the wife to be experiencing some PTSD symptoms just from the disclosure or as a result of finding her husband viewing pornography. The tendency is to lean toward being too empathetic to the wife who has just experienced trauma and forget to show empathy to the male client that is also experiencing trauma. The male's trauma is often from being caught or being asked to make a disclosure, not knowing if that disclosure could risk his marriage. This is important for me to remember or I could lose the trust of the husband in our future work. It is important to remember that he has a "story", and that story is often full of shame. I need to be thinking about how to respond to him by not creating more shame, despite feeling the tug emotionally and sometimes codependently from the wife to align with her. I especially need to be aware that the wife in this scenario may be coming in with a lack of trust in me as a male therapist because of what she has experienced.
Second, I need to provide a "secure base". I need to provide for my clients what a securely attached parent would provide for a child who was anxious and crying. This may include: mirroring, validating and empathy for each client. Harville Hendrix (2007) describes these three elements of attunement as the "Couple's Dialogue". I also want to provide what Carl Rogers (1980) calls "core conditions" in counseling. They are empathy, congruence and unconditional positive regard. I also want to be balanced in my interactions with both clients, and be systemically attuned to not internally labeling one client as the identified problem. I am also assessing their attachment styles and wondering how they are being triggered in those styles. I know from experience that under stress, these attachment styles and the emotions and behaviors that go with them, tend to get put into motion. I am also assessing and wondering about each client's ability to regulate and self sooth their emotions as they sit in front of me. I am aware of the pace of the session and cautious of either client being triggered in their fight or flight response. If I see this, I need to be able to help bring the intensity down, and possibly open the counseling door and allow clients some space if needed to walk and take a break. This tends to help the body not feel trapped. It only works though if both clients know ahead of time, that their partner is not leaving or "abandoning them" in the session.
Finally, I want to watch and assess for the couple's interactive pattern. I want to see how the couple interacts, how they communicate. As I assess, I am wondering if their style of communication is breeding more trauma in their relationship. In my experience of working with couples that come into counseling with these type of presenting issues, this is often the case. There is likely a long history of traumatic interactions that have either been fueled by trauma they have either experienced in the past together, or as individuals. That past trauma then gets triggered in the current relationship. I can then begin using some of the techniques learned from Emotionally Focused Therapy. Emotionally Focused Therapy is an evidenced based practice model used in working with couples. Susan Johnson developed this model. Johnson (2005) suggests a stage approach in working with couples who present with trauma and the resulting negative interactive cycle. The first stage includes: assessment, identify the negative cycle, assess underlying attachment emotions, and frame the problems based on the cycle, the attachment needs and fears. As I assess and identify the negative cycle of interaction that is before me, I can begin to reframe some of the deeper level emotions with my clients. All along, I am keeping the goals of Emotionally Focused Therapy at the back of my mind. These goals include: to expand and reorganize key emotional responses, create a shift in partner's interactional positions and initiate new cycles of interaction through corrective emotional experiences and lastly to foster the creation of a secure bond between partners.
Johnson (2005) authored a book called, Emotionally Focused Couple Therapy with Trauma Survivors. In that book she evokes the image of the dragon as a metaphor in describing the power of trauma and its ability to breathe fire into the lives of survivors and their partners. She goes on to say that the dragon's fire is the helplessness, isolation and betrayal that are at the core of most traumatic experiences. She suggests the power of a secure attachment can be the antidote to the effects of the fire.
As you can see, our work as therapists can be taxing and require a lot of emotional energy. Trauma work is also slow process and requires therapists to be mindful of each step of the way. When we help clients begin to "slay the dragon", we are reminded of the important and rewarding work we do.
References
Hendrix, H. (2007). Getting the love you want. New York, NY: Henry Holt and Company.
Johnson, S. (2005). Emotionally focused couple therapy with trauma survivors: Strengthening attachment bonds. New York, NY: Guilford Publications.
Rogers, C. (1980). Way of being. Boston: Houghton Mifflin.
