New Journal Article on the Importance of Relationships in Trauma Therapy

As you have probably guessed based on my blog, I have a beef with the misrepresentation of effective trauma therapy as being narrowly evidence-based, which often leads people to conclude that the best therapies are the most studied, which often defaults to cognitive-behavioral therapies. But, what the general public less frequently hears about is the vast evidence-based, research literature showing that the therapeutic relationship is the most important ingredient in effective trauma therapy (and therapy for lots of other disorders for that matter). Here’s a really cool new article that supports this fact.

Norcross, J. C., & Wampold, B. E. (2019). Relationships and responsiveness in the psychological treatment of trauma: The tragedy of the APA Clinical Practice Guideline. Psychotherapy, 56(3), 391-399.

http://dx.doi.org/10.1037/pst0000228

Abstract

The therapeutic relationship and responsiveness/treatment adaptations rightfully occupy a prominent, evidence-based place in any guidelines for the psychological treatment of trauma. In this light, we critique the misguided efforts of the American Psychological Association’s (APA, 2017) Clinical Practice Guideline on Posttraumatic Stress Disorder in Adults to advance a biomedical model for psychotherapy and thus focus almost exclusively on treatment methods for particular disorders. Instead, the research evidence, clinical expertise, and patient preferences and culture (the necessary triumvirate of evidence-based practice) should converge on distinctive psychological guidelines that emphasize the therapy relationship, treatment adaptations, and individual therapist effects, all of which independently account for patient improvement more than the particular treatment method. Meta-analytic findings and several trauma-specific studies illustrate the thesis. Efforts to promulgate guidelines without including the relationship and responsiveness are seriously incomplete and potentially misleading. The net result is an APA Guideline that proves empirically dubious, clinically suspect, and marginally useful; moreover, it squanders a vital opportunity to identify what actually heals the scourge of trauma. We conclude with recommendations for moving forward with future APA practice guidelines. (PsycINFO Database Record (c) 2019 APA, all rights reserved)

The Center of the World

A set of parents took a step back to ask if our discrete trauma treatment for their children was taking into account the impact of the horrible event on them, a question their couple’s therapist had asked them to ask. Without fully understanding what was meant, I shared the itch gnawing my intuition: I didn’t know the husband yet and his presence often disappeared from the room. The wife agreed that her husband wasn’t “therapized" like she was. He defended by saying that he’s been in plenty of years of therapy.

But, she’s been in therapy for years and years, and therapy revealed to her that she had been living in the world as is, but there was a floor beneath the world—one filled with nuance, complexity and layered meaning. Over the years, she realized that the floor was actually just a hallway to floors upon floors until you reach the center of the world, and she loved living in that world, exploring its ever changing and revealing landscape. Her husband only visited a few floors from time to time.

I actually freaked out for a second. How did she know about this world?! Who showed her?! I felt both validated and banal and needed to know the name of her therapist.

Afterwards, the nature of our trauma work plunged into the gravity of Kairos.

Transforming the Ember of Rage

I met a man who experienced unbearable, unspeakable
and unspoken horrors at the hands of his
parents. He observed
that when they died he
grieved for just a moment, before
moving to the comfort of anger,

anger at the fact that they
would never be
able to restore his childhood
so violently wrenched. Then,
for the next ten minutes, he lost himself
in this rage against the world.

When he spoke of this grieving rage, I imagined
sifting through the ashes of a dying fire
discovering a weak ember of life.

But, as his rage engulfed, this ember
turned into a blaze of Pyrrhic victory burning
everyone.

I hurriedly gathered that ember
gingerly nursing it without igniting it,
to light a torch illuminating
the path to what he is truly fighting for.

I told him that he should fight
to reclaim his childhood—to be
surrounded by the safety
of love, so he can finally
play.

Fighting for Love

A beautiful autumnal woman dragged her handsome winter boyfriend in
for one last desperate attempt to make this miracle work.
Her history of abandonment triggered by his enacted history of neglect.
He yearns for her, like tiny arms reaching for the mother
who left him stranded on a front yard
at an age too young
to understand in any other way than
he’s not worth taking.

He’s slipped past therapy his whole life,
a lesson in never letting anyone get close enough to hurt him or see his un-worth.
Christmases in the Caribbean, avoiding all reminders of love and family.

But, for her,
anything.

So she lashes him with wet tears,
angry when he turns away,
scared that this will push him away,
guilt-ridden knowing his history, but blinded by her own pain
and her own needs.

I help her see
herself as fighting,
fighting for love, fighting.
Fighting for “I deserve better.”
“We deserve better.”

He shrinks in self-absorbed self-flagellation, reliving
his unworthiness in every
cell. A prisoner
of his pain.

Now, I get angry.
I refuse to let him disappear.
I yell, “Do not leave her!
And, do not leave yourself on that front yard again.
Fight for her! Fight for yourself!
Open your heart and embrace her pain.
The greatest challenge and the greatest reward
left undone in your life is
to feel
to hurt
to love
to hold
and never, ever, let go again.

The Wisdom of Negative Emotions

Part of the work with one patient revolves around this question: What is the value of sitting in uncomfortable emotions?

My patient tells me that his teen-age cousin from out of town is visiting him over the holidays. This is a cousin whom he wishes he could know better and support more. They and some other family members are having a holiday meal. My patient asks the teen what gift she is giving her mother for Christmas and the teen says, "Nothing, I hate her." My patient understands that the teen and her mother are struggling quite a bit, but he doesn't like the negativity displayed so publicly during a holiday meal. Over the course of the meal, my patient grows more and more annoyed by the teen's endless chatter about nothing and can't wait for the evening to end. He ends up feeling guilty for harboring such negative feelings towards his dear cousin and thinks maybe he's just not very patient with teenagers and is a bad older cousin.

After receiving his permission to offer some advice, I tell him that he can't dismiss his annoyance because it holds wisdom and insight about what he really cares about. His annoyance is telling him that he is frustrated in his desire to have a meaningful moment with her so that he can really get to know her as a person, a longing he himself expressed earlier in the session when he said so beautifully,

"I don't really know if my father ever thinks about me when I'm not in front of him."

Secondly, his annoyance is telling him that he really cares about feeling gratitude for the moment that they are able to share together with other family members during that meal.

At the same time, I remember how deeply he appreciates his mother's love for him. I visualize one of the earliest memories he has shared with me--sitting on her lap while reading a book--overlaid onto an image of the same energy holding him over the phone while she listens to him speak as an adult. I don't mention this explicitly, but feel it settling into my heart and coloring my experience of the moment.

Next, I imagine how he might be guided by what he cares about. I tell him I imagine him whispering to his cousin, "I wish we had more time to really talk and
get to know each other."
Like a hug.


Then, I imagine his cousin's energy settling and easing
out of her anxious wanting to be seen while being afraid of being judged,
manifest as the endless babble about nothing.

And in that same moment,
my patient's energy is settling,
his self consolidating, as
he sees himself more
compassionately
and imagines himself more
powerful and effective
in the world, achieving
the knowing he wishes for his cousin
and for himself.

My Therapist's Journey: Play Therapy

The second biggest pillar of my early training was play therapy. I probably did more play therapy than anything else during grad school because I had a part time job placed in an elementary school treating about 15 children per week.

Children taught me a lot about how to bring spontaneity and playfulness into my work. Children will not put up with a neutral, distant person and will tell you whether you are doing right by them, whether you like it or not. If you listen, they will teach you how to be the therapist they need, but you still need to play and experiment for them to know "yes, more" or "no."

When I was thrown into play therapy, I never really received any clear instruction on how to be therapeutic. I even took a semester-long class on child therapy but didn't learn a thing about technique, just a bunch of theory. Now, it is true that some of the developmental and dynamic theories were informative and I found that children's imaginative play often paralleled real-life themes. For example, one five-year-old only watched Lion King up to the point of the father's death and then rewound the tape over and over again. Other children play out generalized themes of powerlessness, fear, family stress, social stress, anger or sadness. But, this work was plodding and it was often difficult to know how to make this play helpful in the real world. Furthermore, many young children quickly grow out of pretend play beginning around age 7 and move into board games and other rule bound games.

It was through hours of playing Uno and Sorry and Trouble that I began to understand that children at this stage were practicing a variety of skills: turn-taking, following the rules, reciprocity, fairness, impulse control, controlled aggression, good sportsmanship, decision making, frustration tolerance, planning, etc. I really began to understand moment to moment activities in terms of what skills or neuro-cognitive functions were being expressed and exercised.

I also had the amazing fortune of learning Ross Greene's Collaborative Problem Solving Approach early on and co-led parenting groups with him in an outcome study comparing his approach to Russell Barkeley's Defiant Child approach, which is a classic behavior management approach. I was beginning to see behavior as being the shaped by external reinforcements (as highlighted in behavior management), neurocognitive drives and deficits (Ross Greene), and internal psychic and relational drives (psychodynamic).

I was becoming more and more interested in diving deep into the moment-to-moment world of play and overlaying these paradigms onto the immediate behaviors and experiences. I started to care more about how things are being said and done versus what was being said or done. In fact, I rarely ever asked children how they were doing or bothered with helping them "open up." Instead, I just played as hard as I could. I tried to really imagine all of the imaginary actions happening between characters. I competed in board games with gusto. I began to figure out what the issues were as they emerged in moment to moment play and tried to figure out ways to correct them without leaving the play.

This obsession with the moment to moment process has carried with me throughout my work and remains a core aspect of how I work and what makes me effective. I listen and observe on so many levels at once: what's being said or done, how, when, why now, how it's connected to history or to other relationships, what's the deficit or the struggle, what's the yearning or aspiration, what's the hurt and pain?

In future posts, I'll give a nod to cognitive-behavioral approaches and then spend a lot more time on modern relational approaches as applied to individual and family work.

The Truth about Trauma Work

I was working with a couple terrorized by demons of severe trauma experienced as children, re-inflicted on each other. They lashed out at each other trying to cause as much pain on the other as they felt themselves. 

And I dove in head first with barely a safety line in tow. 

Utterly uncertain that I would be effective or helpful. 
In a zone. Half unconscious. 
Trying desperately, 
using everything I've learned, making stuff up along the way. 
Tracking them to see what worked; 
stabbed with pangs of regret and doubt when it didn't. 
Moving in and out of panic and beautiful poignancy. 

The session focused on de-escalating the husband, he with a history of violence, while
monitoring the fear and the fury in her eyes who suffered the violence. 
Trying to stay empathic to his pain, while
not forsaking the pained by pushing him
to acknowledge the pain he has caused. 
He moved between ferocious disappointment that everyone let him down and his unbearable shame that he in turn disappointed others in ways nigh unforgivable. 

My heart ached for him. 
Holding both his suffering and his crime was unbelievably difficult
and only possible for me because of the painful work
of accepting my own crimes and broken parts. 
It triggered in me a deep sense of sadness, shame, acceptance, and  compassion. 
Then tenderness, for both of us. 

I stayed with him, 
brushing aside the hurtful parts, mining for the hurt. 
Digging barehanded for shrapnel lodged in his heart, without anesthesia. 
Phantom pain from my own shrapneled heart burning in resonance. 

When something did work, it didn't feel like I could take credit. I'm so aware of how often the very same acts fail with someone else or in some other moment. The only conclusion I come back to again and again leaves me with a deep gratitude for the angel of therapeutic healing that blessed us that day and for the courage of my patients who grace us to co-create these magical moments greater than anything we could imagine or will alone. 

My Therapist's Journey Part 1: Insight.

I've learned so many different types of therapies over the past 20 years and continue to take from everything I’ve ever learned. In a series of posts, I'm going to share what I've personally learned about therapy and becoming a therapist. I hope these posts help future therapists embrace their own journeys and help patients feel more informed and empowered to seek good and smart therapists rather than good and smart therapies that fit their needs in their current moment. 

Read More

Ode to A Depressed Person

I know someone who always feels like ending her life. I told her that I admired the way she lived, which is a ridiculous thing to say. Why would anyone admire someone who is always at baseline suicidal? I tried to unpack what I meant by it and this is what came out:

You, who bears this unrelenting weight of depression,
wake every morning and ask, "Why not today
finally Rest?" 

I know for you
life drags on
despite your protestations,

but I believe that you
more than anyone else has
this remarkable opportunity
, or maybe undesired obligation,
to choose life
every
moment.

See, for you, life
is not a given, 
like the certainty of sunrise.

Every morning, you must choose,
stay or go? 
Every morning, you ask yourself, why stay?
How do I make
today
at least bearable
and possibly worthwhile? 

Then,
to see you be kind and generous and loving,
I am left concluding,
that love alone fulfills life's purpose. 

And, I am reminded that for me love is the source from
which all worthwhile things must spring
(I worry so much about how much hate drives our politics these days)

Then, I feel
reaffirmed, revitalized,
and grateful, for you, who bears this weight, 
reminding me to love and
act in all ways from love.

My Patient's Lovely Description of Our Therapy

It's like you hold up a mirror and I really don’t want to look into it because I think I am so ugly, but deep inside I wish I were cute and pretty (she tears up). But, you keep holding up the mirror and show me that I just have some dirt on my face and you help me brush it off. Then I begin to realize that maybe I’m not so ugly...

Read More

Today's Touching Family Moment

Today a man,
who just months ago
was unsure
whether he wanted family therapy
(at least with me)
then only wanted to work on problem solving,
then only wanted to intellectualize,

finally cried
about missing his father,
grieved the imminent loss of his favorite uncle,
and shared how he suffers
a desperate longing
to connect
with his teen-age son
(who can't make sessions
because of other commitments).

And his wife and daughter
leaned into his pain
with tears in their eyes,
not talking,
not problem solving,
only conveying
love
and gratitude.

And I too honestly
felt moved
like listening to Adele
or singing Karaoke :-) 

And I reassured the father
that this new man
will draw his son
inexorably
like love
is wont to do.