As a trauma therapist, I have a front row to suffering that on occasions leaves a lasting impression on me. I am exposed every day to the distress of others that has me bear witness to traumatic, terrifying and cruel events that can include images, some of which have left me haunted years after my client has left. I have not been immune to the complication of an individual trauma morphing into something collective with my own demons re-activated by a clients experience. I am aware that to be able to support and be present to and for my clients fully I need to take care of myself and this is something that I now recognise as a priority that in my earlier years I didn’t take into consideration.
I am not sure that anyone mentioned secondary or vicarious trauma in my earlier trainings to be a Psychotherapist. It was only when doing a specific trauma training with Babette Rothschild that I really understood the risks of developing traumatic stress disorders that can mimic the PTSD of clients as a result of listening to their trauma narratives. Up until then, there was undoubtedly an unspoken expectation I had of myself that I ‘should’ be able to cope with every story. I hadn’t stopped to consider that, whereas a client has to come to terms with their individual trauma, I would be exposed to dozens if not hundreds of traumas.
The ‘should’ became more about my own self care as part of being able to manage the inevitability of haunting stories and images that would, on occasion, penetrate me to the core. Personal therapy, supervision and talking with trusted colleagues has been a way I have found to decompress, offload and gain perspective instead of repressing the traumatic content for it to emerge for rumination at a later stage. Without finding our own way to take care of ourselves working with trauma can change the way, we view the world as our clients unknowingly plant lasting images in our minds that can leave us deeply troubled. By taking care of ourselves, we are then able to hold and contain the horrors that our clients have endured so that they can find a way back to their lives.
There is no doubt that we cannot help but have moments where we are deeply impacted by our clients stories – what has been done to them as well as what they have done. Many clients who have been severely traumatised have never had the reality of the horror validated. Learning to hold the balance between being impacted and at the same time responding to our clients traumas with empathy and poise without retreating, or changing the subject, takes awareness of our own triggers and vulnerabilities. It is also an active intervention as by being able to meet as well as validate strong emotions and challenging stories we are showing our clients that their feelings, although they might feel dangerous and overwhelming, are welcome despite their intensity.
I have witnessed the transformative effect of trauma therapy on many clients and believe in the importance of pacing trauma work appropriately. There are vital steps to put in place mainly as it is commonly acknowledged that those with PTSD have a susceptibility to becoming traumatised again, hence taking time to establish suitability is imperative before even considering addressing trauma. By the time a client comes to therapy, there is often a sense of urgency to resolve their issue. I am so aware of my own curiosity when meeting a new client and am mindful of how much detail my client shares with me, especially in the first few sessions. It is a fine balance between what information and detail of a trauma is helpful for the client and where it is perhaps not only unhelpful for the client, but also for myself as a therapist. This is an area where we need to be guided by our intuition and be clear that any question we ask is for the benefit of the therapy, not just to feed our curiosity. Peter Levine in his book ‘Waking The Tiger’ talks about how we need to ‘gently slide into trauma and then draw ourselves gradually out.’ Confronting trauma head on often results in immobilising us in one way or another and can, in some instances, pose a threat to life, the pacing of trauma therapy is fundamental to its success or not.
Creating a safe container is of paramount importance so that a client feels safe enough to start to venture into territories that hold traumatic memories for them. The relationship between client and therapist is a partnership where both decide and agree together the direction and focus of the therapy rather than the therapist taking control of what the client ‘should’ do. As each of us is different, I believe it is essential for us to be flexible in our way of working, tailoring the therapy to the needs of our client. Although there is much value in models, theory and techniques, we need to be able to put all those to one side and meet our clients where they are and go at a pace that keeps them safe and contained.
Many of us have disconnected from our felt sense as a result of traumatic experiences, and so starting to re-connect can be challenging and needs to be taken slowly. Rothschild speaks to the importance of supporting our clients in understanding the workings of their sensory nervous system. She advocates the importance of dual awareness – the balancing of both interoceptors and exteroceptors. She maintains that if the traumatic hyper arousal goes too high, the client is not going to be able to think, nor digest and integrate the therapy and the possibility of re-traumatisation increases. Rothschild talks about ‘putting on the brakes,’ which is vital to ensure that clients can participate in therapy without becoming hyper aroused and part of my role is to be able to intervene at any stage in order to maintain emotional and physical safety.
Teaching our clients to pay attention to their internal experience as well as paying attention to their external environment enables clients to make a connection with the here and now, which is especially important when working with trauma. As clients learn to identify times when their nervous system becomes too aroused versus when their nervous system relaxes they can gauge what is beneficial and what is detrimental to them. They can learn how to move from interoceptor to exteroceptor, or to alternate between the two as a way of keeping safe.
Due to the stressful nature of working with trauma, we need to be able to do what we ask of our clients. In moments of stress we need to be able to track what is happening in our bodies and our own emotional responses incase countertransference, vicarious trauma or a trigger sets us on the path to be in a worse emotional state than our client.Thus, understanding our nervous system is vital for both therapist and client as it makes the therapy safer for the both of us. Most of us take our breath for granted. We don’t stop and think about the depth or quality of our breath. Working on keeping our clients safe, in order to do trauma work, teaching them how to take deep breathing seriously as a way of calming their nervous system is one of the most helpful and natural interventions we can do.
Considering that most clients come to therapy once a week, there are many hours whereby a client will need to find alternative meaningful and helpful ways to manage both the intensity of the sessions, as well as life outside of the therapy room. With this in mind working with our clients to develop a toolbox of alternative resources, outside of therapy, that they can identify and cultivate enables them to feel more in control of their lives.
Most clients unknowingly already have a fair few resources that they can rely on to help calm their autonomic nervous system and that offer moments or feelings of calm, safety and support: family members, friendships, community, place of work and workshop. Hobbies, meditation, communing in nature, animals and inanimate objects are only some of the things that come to mind. With our help, clients can start to consider and expand on what they already have available to them along with perhaps developing new resources.
One of the resources I often use with my clients is having them take time to establish in their minds eye a place of safety. I get them to describe it in detail. What they see, hear, smell and feel. As a resource, knowing that we can find a place of safety inside of ourselves at any given moment, enables our client to trust that if they find themselves feeling overwhelmed they can use this or any of their other resources to calm and comfort themselves.
For me, as I sit with my clients, I feel held in the knowledge that there is an old black and white photograph taken over fifty five years ago of my sister that sits on a shelf that at a glance I can see. She died when a little girl ……… an enormous loss for me. She is looking directly into the camera, which seems as if she is looking directly at me. In my moments of anxiety, hyper arousal or distress, I glance up at her and breath in the gift of her look that I believe says ‘you are not alone …….. all will be well …….. breath.’