For Therapists Treating Complex PTSD
This following is by Pete Walker and Pete has kindly given me permission to use his work here.
Attachment Disorder and Complex PTSD
Many traumatologists see attachment disorder as one of the key symptoms of Complex PTSD. In the psychoeducational phases of working with traumatized clients, I typically describe attachment disorder as the result of growing up with primary caretakers who were regularly experienced as dangerous. They were dangerous by contemptuous voice or heavy hand, or more insidiously, dangerous by remoteness and indifference.
Recurring abuse and neglect habituates children to living in fear and sympathetic nervous system arousal. It makes them easily triggerable into the abandonment mélange of overwhelming fear and shame that tangles up with the depressed feelings of being abandoned.
A child, with parents who are unable or unwilling to provide safe enough attachment, has no one to whom she can bring her whole developing self. No one is there for reflection, validation and guidance. No one is safe enough to go to for comfort or help in times of trouble. There is no one to cry to, to protest unfairness to, and to seek compassion from for hurts, mistakes, accidents, and betrayals. No one is safe enough to shine with, to do “show and tell” with, and to be reflected as a subject of pride. There is no one to even practice the all-important intimacy-building skills of conversation.
In the paraphrased words of more than one of my clients: “Talking to Mom was like giving ammunition to the enemy. Anything I said could and would be used against me. No wonder, people always tell me that I don’t seem to have much to say for myself.”
Those with CPTSD-spawned attachment disorders never learn the communication skills that engender closeness and a sense of belonging. When it comes to relating, they are often plagued by debilitating social anxiety—and social phobia when they are at the severe end of the continuum of CPTSD.
Many of the clients who come through my door have never had a safe enough relationship. Repetition compulsion drives them to unconsciously seek out relationships in adulthood that traumatically reenact the abusive and/or abandoning dynamics of their childhood caretakers.
For many such clients, we are their first legitimate shot at a safe and nurturing relationship. If we are not skilled enough to create the degree of safety they need to begin the long journey towards developing good enough trust, we may be their last.
Emotional flashback management, therefore, is empowered when it is taught in the context of a safe relationship. Clients need to feel safe enough with their therapist to describe their humiliation and overwhelm. At the same time, the therapist needs to be nurturing enough to provide the empathy and calm support that was missing in the client's early experience.
Just as importantly, the therapist needs to be able to tolerate and work therapeutically with the sudden evaporation of trust that is so characteristic of CPTSD. Trauma survivors do not have a volitional "on" switch for trust, even though their "off" switch is frequently automatically triggered during flashbacks. In therapy, the therapist must be able to work on reassurance and trust restoral over and over again.
The therapist needs to be able to tolerate and work therapeutically with the sudden evaporation of trust that is so characteristic of CPTSD.
I have heard too many disappointing client stories about past therapists who got angry at them because they would not simply choose to trust them.As the importance of this understanding ripens in me, I increasingly embrace an intersubjective or relational approach. That means that I believe that the quality of the clients’ relationship with me can provide a corrective emotional experience that saves them from being doomed to a lifetime of superficial connection, or worse, social isolation and alienation.
Moreover, I notice that without the development of a modicum of trust with me, my CPTSD clients are seriously delimited in their receptivity to my guidance, as well as to the ameliorative effects of my empathy. In this regard then, I will describe four key qualities of relating that I believe are essential to the development of trust, and the subsequent relational healing that can come out of it. These are empathy, authentic vulnerability, dialogicality and collaborative relationship repair.
I used to assume that the merits of empathy were a given, but I have sadly heard too many stories of empathy-impoverished therapy. In this regard, I will simply say here that if we are hard and unsympathetic with our clients, we trigger the same sense of danger and abandonment in them that they experienced with their parents.In terms of a definition, I especially like Kohut’s statement that: “Empathy involves immersing yourself in another’s psychological state by feeling yourself into the other’s experience.”
When I delve deeply enough into a client’s experience, no matter how initially perplexing or intemperate it may at first seem, I inevitably find psychological sense in it, especially when I recognize its flashback components.
I have sadly heard too many stories of empathy-impoverished therapy.
In fact, I can honestly say that I have never met a feeling or behavior that did not make sense when viewed through the lenses of transference and traumatology.
Empathy, of course, deepens via careful listening and full elicitation of the client’s experience, along with the time-honored techniques of mirroring and paraphrasing which show the client the degree to which we get him.
Noticing my subjective free associations often enhances my empathic attunement and ability to reflect back to the client in an emotionally accurate and validating way. When appropriate, I sometimes share my autobiographical free associations with the client when they are emotionally analogous. I do this to let her know that I really empathize with what she is sharing.Following is an example. My client tells me with great embarrassment that she stayed home all weekend because she had a pimple on her nose.
She is ashamed of the pimple and of her “vanity’’ about it. She moans: “How could I be so stupid to let such a little thing bother me?” I suddenly remember cancelling a date once when I had a cold sore. At the time, I also got lost in a toxic shame attack. I share this with her, minus present day shame about it. She tears up and then laughs, relieved as her shame melts away. Months later, she tells me that her trust in me mushroomed at that moment. Guidelines for being judicious about this kind of self-disclosure will be discussed below.
Of the many benefits of empathy, the greatest is perhaps that it models and teaches self-empathy, better known as self-acceptance. To the degree that we attune to and welcome all of the client’s experience, to that same degree can the client learn to welcome it in her- or himself.
2. Authentic Vulnerability
Authentic vulnerability is a second quality of intimate relating which often begins with emotionally reverberating with the client. I have found that emotional reflection of the client’s feelings is irreplaceable in fostering the development of trust and real relational intimacy.Emotional reflection requires the therapist to be emotionally vulnerable himself and reveal that he too feels mad, sad, bad and scared sometimes. Modeling vulnerability, as with empathy, demonstrates to the client the value of being vulnerable and encourages her to risk wading into her own vulnerability.I came to value therapeutic vulnerability the hard way via its absence in my own therapy with a therapist who was of the old, “blank screen” school. She was distant, laconic and over-withholding in her commitment to the psychoanalytic principle of “optimal frustration.” Therapy with her was actually counter-therapeutic and shame-exacerbating for me as we reenacted a defective child/perfect parent dynamic.
Therapeutic Emotional Disclosure
Thankfully, I eventually realized that I had unresolved attachment issues, and sought out a relational therapist who valued the use of her own vulnerable and emotionally authentic self as a tool in therapy. Her tempered and timely emotional self-disclosures helped me to deconstruct the veneer of invincibility I had built as a child to hide my pain. Here are some examples that were especially helpful. “God, the holidays can be awful.” “I get scared when I teach a class too.” “I’m so sorry. I just missed what you said. I got a little distracted by my anxiety about my dental appointment this afternoon.” “I feel sad that your mother was so mean to you.” “It makes me angry that you were so bullied by your parents.”
My therapist’s modeling that anger, sadness, fear, and depression were emotions that could be healthily expressed helped me to renounce the pain-repressing, emotional perfectionism in which I was mired.
My therapist’s modeling that anger, sadness, fear, and depression were emotions that could be healthily expressed helped me to renounce the pain-repressing, emotional perfectionism in which I was mired.
With her, I learned to stop burying my feelings in the hope of being loved. I renounced my just-get-over-it philosophy and embraced vulnerability as a way of finally getting close to people.I needed this kind of modeling, as so many of my clients have, to begin to emerge from my fear of being attacked, shamed or abandoned for feeling bad and having dysphoric feelings. In order to let go of my Sisyphean salvation fantasy of achieving constant happiness, I needed to experience that all the less than shiny bits of me were acceptable to another human being. Seeing that she was comfortable with and accepting of her own unhappy feelings eventually convinced me that she really was not disgusted by mine.
The therapist’s judicious use of emotional self-disclosure helps the client move out of the slippery, shame-lined pit of emotional perfectionism. Here are some self-revealing things that I say to encourage my clients to be more emotionally self-accepting. “I feel really sad about what happened to you." "I feel really angry that you got stuck with such a god-awful family." "When I'm temporarily confused and don't know what to say or do, I…" “When I’m having a shame attack, I…” “When something triggers me into fear, I…” "When my inner critic is overreacting, I remind myself of the Winnicottian concept that I only have to be a ‘good enough person.’”Here are two examples of emotional self-disclosure that are fundamental tools of my therapeutic work. I repeatedly express my genuine indignation that the survivor was taught to hate himself. Over time, this often awakens the survivor’s instinct to also feel incensed about this travesty. This then empowers him to begin standing up to the inner critic. This in turn aids him to emotionally invest in the multidimensional work of building healthy self-advocacy.
Furthermore, I also repeatedly respond with empathy and compassion to the survivor’s suffering. With time, this typically helps to awaken the recoveree’s capacity for self-empathy. She then gradually learns to comfort herself when she is in a flashback or otherwise painful life situation. Less and less often does she surrender to an inner torture of self-hate, self-disappointment, and self-abandonment.
My most consistent feedback from past clients is that responses like these—especially ones that normalize fear and depression—helped them immeasurably to deconstruct their perfectionism, and open up to self-compassion and self-acceptance.
Guidelines for Self-Disclosure
What guidelines, then, can we use to insure that our self-disclosure is judicious and therapeutic? I believe the following five principles help me to disclose therapeutically and steer clear of unconsciously sharing for my own narcissistic gratification.
First, I use self-disclosure sparingly.
Second, my disclosures are offered primarily to promote a matrix of safety and trust in the relationship. In this vein my vulnerability is offered to normalize and de-shame the inexorable, existential imperfection of the human condition, e.g., we all make mistakes, suffer painful feelings, experience confusion, etc.
My vulnerability is offered to normalize and de-shame the inexorable, existential imperfection of the human condition.
Third, I do not share vulnerabilities that are currently raw and unintegrated.
Fourth, I never disclose in order to work through my own “stuff,” or to meet my own narcissistic need for verbal ventilation or personal edification.
Fifth, while I may share my appreciation or be touched by a client's attempt or offer to focus on or soothe my vulnerabilities, I never accept the offer. I gently thank them for their concern, remind them that our work is client-centered, and let them know that I have an outside support network.
Emotional Self-disclosure and Sharing Parallel Trauma History
Since many of my clients have sought my services after reading my somewhat autobiographical book on recovery from the dysfunctional family, self-disclosure about my past trauma is sometimes a moot point. This condition has at the same time helped me realize how powerful this kind of disclosure can be in healing shame and cultivating hope.
Over and over, clients have told me that my vulnerable and pragmatic stories of working through my parents’ traumatizing abuse and neglect gives them the courage to engage the long difficult journey of recovering. But whether or not someone has read my book, I will—with appropriate clients—judiciously and sparingly share my own experiences of dealing with an issue they have currently brought up. I do this both to psychoeducate them and to model ways that they might address their own analogous concerns.
One common example sounds like this: “I hate flashbacks too. Even though I get them much less than when I started this work, falling back into that old fear and shame is so awful.”I also sometimes say: “I really reverberate with your feelings of hopelessness and powerlessness around the inner critic. In the early stages of this work, I often felt overwhelmingly frustrated. It seemed that trying to shrink it actually made it worse. But now after ten thousand repetitions of thought-stopping and thought-correction, my critic is a mere shadow of its former self.”
A final example concerns a purely emotional self-disclosure. When a client is verbally ventilating about a sorrowful experience, I sometimes allow my tears to brim up in my eyes in authentic commiseration with their pain. The first time my most helpful therapist did this with me, I experienced a quantum leap in my trust of her.
Dialogicality occurs when two conversing people move fluidly and interchangeably between speaking (an aspect of healthy narcissism) and listening (an aspect of healthy codependence). Such reciprocal interactions prevent either person from polarizing to a dysfunctional narcissistic or codependent type of relating.
Dialogicality energizes both participants in a conversation. Dialogical relating stands in contrast to the monological energy-theft that characterizes interactions whereby a narcissist pathologically exploits a codependent’s listening defense. Numerous people have reverberated with my observation that listening to a narcissist monologue feels as if it is draining them of energy.I have become so mindful of this dynamic that, in a new social situation, a sudden sense of tiredness often warns me that I am talking with a narcissist.
How different than the elevation I sense in myself and my fellow conversant in a truly reciprocal exchange. Again, I wonder if there are mirror neurons involved in this.I was appalled the other day while perusing a home shopping catalog to see a set of coffee cups for sale that bore the monikers “Designated Talker” and “Designated Listener.” My wife and I pondered it for a few minutes, and hypothesized that it had to be a narcissist who designed those mugs. We imagined we could see the narcissists who order them presenting them to their favorite sounding boards as Christmas presents.
In therapy, dialogicality develops out of a teamwork approach—a mutual brainstorming about the client’s issues and concerns. Such an approach cultivates full exploration of ambivalences, conflicts and other life difficulties.
Dialogicality is enhanced when the therapist offers feedback from a take-it-or-leave-it stance.
Dialogicality also implies respectful mutuality. It stands in stark contrast to the blank screen neutrality and abstinence of traditional psychoanalytic therapy, which all too often reenacts the verbal and emotional neglect of childhood.
Dialogicality stands in stark contrast to the blank screen neutrality and abstinence of traditional psychoanalytic therapy, which all too often reenacts the verbal and emotional neglect of childhood.
I believe abstinence commonly flashes the client back into feelings of abandonment, which triggers them to retreat into “safe” superficial disclosure, ever-growing muteness and/or early flight from therapy.
Meeting Healthy Narcissistic Needs
All this being said, extensive dialogicality is often inappropriate in the early stages of therapy. This is especially true, when the client’s normal narcissistic needs have never been gratified, and remain developmentally arrested. In such cases, clients need to be extensively heard. They need to discover through the agency of spontaneous self-expression the nature of their own feelings, needs, preferences and views.
For those survivors whose self-expression was especially decimated by their caretakers, self-focused verbal exploration typically needs to be the dominant activity for a great deal of time. Without this, the unformed healthy ego has no room to grow and break free from the critic. The client’s healthy sense of self remains imprisoned beneath the hegemony of the outsized superego.This does not mean, however, that the client benefits when the therapist retreats into extremely polarized listening. Most benefit, as early as the first session, from hearing something real or “personal” from the therapist. This helps overcome the shame-inducing potential that arises in the “One-seen (client) / One-unseen (therapist)” dynamic.
When one person is being vulnerable and the other is not, shame has a huge universe in which to grow. This also creates a potential for the client to get stuck flashing back to childhood when the vulnerable child was rejected over and over by the seemingly invulnerable parent. Consequently, many of my colleagues see group therapy as especially powerful for healing shame, because it rectifies this imbalance by creating a milieu where it is not just one person who is risking being vulnerable.In this regard, it is interesting to note a large survey of California therapists that occurred about fifteen years ago. The survey was about their therapy preferences, and upwards of ninety percent emphasized that they did not want a blank screen therapist, but rather one who occasionally offered opinions and advice.
For twenty-five years, I have been routinely asking clients in the first session: “Based on your previous experiences in therapy, what would you like to happen in our work together; and what don’t you want to happen?” How frequently clients respond similarly to the therapists in the survey!
Moreover, the next most common response I receive is that I don’t want a therapist who does all the talking. More than a few have used the exact phrase: “I couldn’t get a word in edgewise!”
How I wish there was a way that our qualification tests could spot and disqualify the narcissists who get licensed and then turn their already codependent clients into sounding boards.
How I wish there was a way that our qualification tests could spot and disqualify the narcissists who get licensed and then turn their already codependent clients into sounding boards. This is the shadowy flipside polarity of the blank screen therapist.
Psychoeducation as Part of Dialogicality
Experience has taught me that clients who are childhood trauma survivors typically benefit from psychoeducation about Complex PTSD. When clients understand the whole picture of CPTSD recovery, they become more motivated to participate in the self-help practices of recovering. This also increases their overall hopefulness and general engagement in the therapeutic process. I sometimes wonder whether the rise in the popularity of coaching has been a reaction to the various traditional forms of therapeutic neglect.One of the worst forms of therapeutic neglect occurs when the therapist fails to notice or challenge a client’s incessant, self-hating diatribes. This, I believe, is akin to tacitly approving of and silently colluding with the inner critic.
Perhaps therapeutic withholding and abstinence derives from the absent father syndrome that afflicts so many westernized families. Perhaps traditional psychotherapy overemphasizes the mothering principles of listening and unconditional love, and neglects the fathering principles of encouragement and guidance that coaching specializes in.
Too much coaching is, of course, as counter-therapeutic and unbalanced as too much listening. It can interfere with the client’s process of self-exploration and self-discovery as described above. At its worst, it can lure the therapist into the narcissistic trap of falling in love with the sound of his own voice.At its best, coaching is an indispensable therapeutic tool. Just as it takes fathering and mothering to raise a balanced child, mothering and fathering principles are needed to meet the developmental arrests of the attachment-deprived client.
The sophisticated therapist values both and intuitively oscillates between the two, depending on the developmental needs of the client in the moment. Sometimes we guide with psychoeducation, therapeutic self-disclosure and active positive noticing, and most times we receptively nurture the client’s evolving practice of her own spontaneously arising self-expression and verbal ventilation.
Once again, I believe that in early therapy and many subsequent stages of therapy, the latter process typically needs to predominate. In this vein, I would guess that over the course of most therapies that I conduct, I listen about ninety percent of the time.Finally, I often notice that the last phase of therapy is often characterized by increasing dialogicality—a more balanced fluidity of talking and listening. This conversational reciprocity is a key characteristic of healthy intimacy.
Moreover, when therapy is successful, progress in mutuality begins to serve the client in creating healthier relationships in the outside world.Dialogicality and the 4F’s (Fight/Flight/Freeze/Fawn)Because of childhood abandonment and repetition compulsion in later relationships, many 4F types are “dying” to be heard. Different types however vary considerably in their dialogical needs over the course of therapy.The Fawn/ Codependent type, who survived in childhood by becoming a parent’s sounding board or shoulder to cry on, may use her listening defense to encourage the therapist to do too much of the talking. With her eliciting defense, she may even invoke the careless therapist into narcissistically monologuing himself.
The Freeze/Dissociative type, who learned early to seek safety in the camouflage of silence, often needs a great deal of encouragement to discover and talk about his inner experience. Psychoeducation can help him understand how his healthy narcissistic need to express himself was never nurtured in his family.
Furthermore, freeze types can easily get lost in superficial and barely relevant free associations as they struggle to learn to talk about themselves. This of course needs to be welcomed for some time, but eventually we must help him see that his flights of fantasy or endless dream elaborations are primarily manifestations of his dissociative defense.
Freeze types need to learn that emotionally disconnected talking is an old childhood habit that was developed to keep them buoyant above their undealt with emotional pain.
Freeze types need to learn that emotionally disconnected talking is an old childhood habit that was developed to keep them buoyant above their undealt with emotional pain. Because of this, we must repeatedly guide them toward their feelings so that they can learn to express their most important concerns.
The Fight/Narcissistic type, who often enters therapy habituated to holding court, typically dodges real intimacy with her talking defense. Therapy can actually be counterproductive for these types as months or years of uninterrupted monologuing in sessions exacerbate their sense of entitlement. By providing a steady diet of uninterrupted listening, the therapist strengthens their intimacy-destroying defense of over-controlling conversations. Sooner or later, we must insert ourselves into the relationship to work on helping them learn to listen.
As I write this, I remember Harry from my internship whose tiny capacity to listen to his wife evaporated as my fifty minutes of uninterrupted listening became his new norm and expectation in relationship. I felt guilty when I learned this from listening to a recorded message from his wife about how therapy was making him even more insufferable. I was relieved, however, a few years later when a different client told me that Harry’s wife eventually felt happy about this “therapeutic” change. Her husband’s increased self-centeredness was the last straw for her and she finally, with great relief, shed herself of him.
A therapist, who is a fawn type herself, may hide in a listening and eliciting defense to avoid the scary work of gradually insinuating herself into the relationship and nudging it towards dialogicality. If we do not nudge the client to interact, there will be no recovering.
The Flight/Obsessive-compulsive type sometimes presents as being more dialogical than other types. Like the freeze type, however, he can obsess about “safe” abstract concerns that are quite removed from his deeper issues. It is therefore up to the therapist to steer him into his deeper, emotionally based concerns to help him learn a more intimacy-enhancing dialogicality. Otherwise, the flight type can remain stuck and floundering in obsessive perseverations about superficial worries that are little more than left-brain dissociations from his repressed pain.
It is important to note here that all 4F types use left- or right-brain dissociative processes to avoid feeling and grieving their childhood losses. As dialogicality is established, it can then be oriented toward helping them to uncover and verbally and emotionally vent their ungrieved hurts.
4. Collaborative Relationship Repair
Collaborative relationship repair is the process by which relationships recover and grow closer from successful conflict resolution. Misattunements and periods of disaffection are existential to every relationship of substance. We all need to learn a process for restoring intimacy when a disagreement temporarily disrupts our feeling of being safely connected.
I believe most people, if they think about it, realize that their best friends are those with whom they have had a conflict and found a way to work through it.
I believe most people, if they think about it, realize that their best friends are those with whom they have had a conflict and found a way to work through it. Once a friendship survives a hurtful misattunement, it generally means that it has moved through the fair-weather-friends stage of relationship.Synchronistic with writing this section, my son uncharacteristically got into a conflict at school. During third grade recess two of his good friends, also uncharacteristically, started teasing him, and when they would not stop he pushed each of them. This earned them all a trip to the principal’s office. The principal is a strict but exceptionally wise and kind woman. My son’s offense, using physical force to resolve a conflict, was judged as the most serious violation of school policy, but his friends were also held responsible for their part and given an enlightening lecture on teasing.My son, not used to being in trouble, had a good cry about it all. He then agreed that a one-day loss of recess plus writing letters of apology to his friends were fair consequences. Two days later, I asked him how things were going now between him and the two friends. With a look of surprise and delight, he told me: “It’s really funny, daddy. Now it feels like we’re even better friends than we were before.”Rapport repair is probably the most transformative, intimacy-building process that a therapist can model. I guide this process from a perspective that recognizes that there is usually a mutual contribution to any misattunement or conflict.
Therefore, a mutually respectful dialogical process is typically needed to repair rapport.
Exceptions to this include scapegoating and upsets that are instigated by a bullying narcissist. In those situations, they are solely at fault. I have often been saddened by codependent clients who apologize to their bullying parents as if they made their parents abuse them.In more normal misattunements, I often initiate the repair process with two contiguous interventions. Firstly, I identify the misattunement (e.g., “I think I might have misunderstood you.”) And secondly, I then model vulnerability by describing what I think might be my contribution to the disconnection.
Abbreviated examples of this are: “I think I may have just been somewhat preachy…or tired…or inattentive…or impatient…or triggered by my own transference.” Owning your part in a conflict validates the normality of relational disappointment and the art of amiable resolution.Taking responsibility for your role in a misunderstanding also helps deconstruct the client’s outer critic belief that relationships have to be perfect.
Taking responsibility for your role in a misunderstanding helps deconstruct the client’s outer critic belief that relationships have to be perfect.
At the same time, it models a constructive approach to resolving conflicts, and over time leads most clients to become interested in exploring their contribution to the conflict. This becomes an invaluable skill which they can then take into their outside relationships.
As one might expect, fight types are the least likely of the 4F’s to collaborate and own their side of the street in a misattunement. Extreme fight types such as those diagnosed with Narcissistic Personality Disorder have long been considered untreatable in traditional psychoanalysis for this reason.With less extreme fight types, I sometimes succeed in psychoeducating them on how they learned their controlling defenses. From there I try to help them see how much they pay for being so controlling.
At the top of the list of debits is intimacy-starvation. Consciously or not, they hunger for human warmth and they do not get it from those whom they control. Victims of fight types are too afraid of them to relax enough to generate authentically warm feelings.
Finally, I believe one of the most common reasons that clients terminate prematurely is the gradual accumulation of dissatisfactions that they do not feel safe enough to bring up or talk about. How sad it is that all kinds of promising relationships wither and die from an individual or couple’s inability to safely work through differences and conflict.
Earned Secure AttachmentIn therapy, clients get the most out of their session by learning to stay in interpersonal contact while they communicate from their emotional pain. This gradually shows them that they are acceptable and worthwhile no matter what they are feeling and experiencing.As survivors realize more deeply that their flashbacks are normal responses to abnormal childhood conditions, their shame begins to melt. This then eases their fear of being seen as defective. In turn, their habits of isolating or pushing others away during flashbacks diminish.
Earned secure attachment is a newly recognized category of healthy attachment. Many attachment therapists believe that effective treatment can help a survivor “earn” at least one truly intimate relationship. Good therapy can be an intimacy-modeling relationship. It fosters our learning and practicing of intimacy-making behavior.
Your connection with your therapist can become a transitional earned secure attachment. This in turn can lead to the attainment of an earned secure attachment outside of therapy. I have repeatedly seen this result with my most successful clients, and I am grateful to report that my last experience with my own therapy lead me to this reward.
2014 Pete Walker