Transcript: Episode 282
282: Therapeutic Relationship, Part 1
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So today I want to talk about some stuff from a book called Treatment of Complex Trauma: A Sequenced Relationship-Based Approach by Courtois and Ford. Specifically I want to talk about Chapter Nine, walking the walk the therapeutic relationship, which is all about balancing authenticity with clear professional boundaries. They start by quoting Risking Connection, which is actually a website you can see riskingconnection.com. And they talk about, quote, “the double edged sword of relational engagement in the treatment of or provision of social and human services to the victimized. Risking connection refers both to the traumatized client and to the professional helper. Both personally take a risk when they form a relationship connection that aims to help the client overcome the terror, helplessness and horror of surviving traumatic events and their aftermath.”
And in focusing on the risk for the therapist, they talk about vicarious trauma. Vicarious trauma was, quote, “first described and defined as therapists post traumatic stress reactions, resulting from hearing their clients stories and learning about their post traumatic reactions and impairments, and from interacting with the traumatized.” End quote. This can also be called compassion fatigue, or secondary trauma, or empathetic strain, depending on sort of what, who you're reading. But it refers to the process of change or transformation, personal as well as professional, in the helper as a result of relational engagement with, and provision of, services to survivors of trauma.
So they talk about how survivors don't traumatize their therapist on purpose, and how the experiences of survivors stories don't just by default traumatize the therapist. But the over-exposure to these stories and the intensity of these stories, and the ongoing long term nature of survivor treatment can develop similar symptoms in therapists. And so basically, at the very least, that's part of why self-care is so important, right? But the care of the therapist in that context is really on the therapist, it is not the client's responsibility to do that. Especially as that reenacts parentified development, which is a trauma response where children were neglected and had to care for their parents or manage their parents’ emotions instead of their own.
The authors also remind therapists that this secondary trauma that they are processing is less daunting than what the survivor actually lived through. But at the same time, it's still important to take care of yourself as you're helping survivors so that you are in a good and healthy place as part of good boundaries for the relationship, so that it can stay healthy. Because the therapeutic relationship is everything.
So then they talk about how with survivors of relational traumas specifically, how the relationship, the caregiving relationships that survivors had in the past were not actually accessible to the survivors through relationship because that's where the trauma was, right? Especially when it impacted attachment or was a betrayal kind of trauma where the relationship that was supposed to be caregiving was also the relationship that was causing harm. And so because of this what clients need often is not asked for through words. Instead, it's acted out through the relationship or communicated implicitly through coded behaviors or interactions. So rather than asking for what they need, they self protectively pushed away from others due to fear of being rejected and abandoned.
So, this is common in relationships, or friendships, or the therapeutic relationship, any of those. In those relationships with survivors, there's always this push-pull. And sometimes it can feel very borderline, if people are stereotyping, or it can be misdiagnosed as a personality disorder. But that push-pull isn't just ‘come get close to me, no, get away from me’. that's really oversimplifying what's going on. It’s an indicator of betrayal trauma, specifically. And it means they are literally not feeling safe enough to ask for what they need. And, and do not have capacity to ask for what they need. So almost always, in those moments, they actually need closeness. But because closeness has been dangerous, they push away the closeness or sabotage the closeness or avoid the closeness depending on if they're a fight or a flight or a freezer, and act out what is going to keep them safe, which may not actually meet their needs, because they still prioritize safety over meeting their needs. And not getting their needs met is not actually going to keep them safe. So even that can cause fatigue or discouragement on the part of the therapist.
But the therapist needs to remember that entering that space, or as Courtois and Ford say entering that void, is part of forging a genuine relationship, that can be a source of renewal and reengagement for both the therapist and the client. But it takes participation in, and responsiveness to, that relationship for clients to actually feel better, much less get better, especially if they have betrayal trauma or relational trauma. And this is huge. Because if we are so focused on technique or modality, or if we're only telling clients that they have a choice in how they respond, or that we’re only trying to work with them through talking, it's not actually going to work, because that's not what develops a relationship for them. Especially with relational trauma because words were what set up the rules of the relationship to keep the person safe through compliance, which is not the same as a relationship. That was the abuse.
So only talking, or only, or putting the brunt of the weight of healing on the client by expecting them to participate in a particular way, or getting frustrated or irritated that they're not choosing or not engaging, those things will actually cause ruptures. That can be very dangerous, either increasing the likelihood that they quit therapy or even increasing suicidality because it adds to shame, and it shames them for something that is a capacity issue. They are not able to do that. And we know this about the frontal cortex being offline. When the prefrontal cortex is offline or when the cortex is offline, they literally can't do a top down thing where it's simply a matter of choosing to do things differently, or talking yourself through something or using your coping skills. That's not always how it works. And that's not always accessible. So if they are shamed for what they're not actually capable of doing that does not feel like hope. Even if it's wrapped up in positive statements or blanket affirmations, it doesn't feel like hope. It feels like despair because it doesn't work. And they know that. Which leaves them feeling hopeless and helpless, instead of feeling empowered. It backfires. And when that happens, it feels like there is no source of hope, because they are there in therapy, trying to get help, and it's not being helpful. And that's a dangerous place for clients to be.
Courtois and Ford said, quote, “suffice it to say that it is not enough for therapists to simply encourage their clients to trust them, and feel secure in the therapeutic relationship. In order for therapy to provide a genuinely secure emotional base, the therapist must have a personal working model of relationships that is secure, and a related ability to emotionally self-regulate. This does not require that the therapist be perfect or free from insecurity. Rather, it is the therapist ego strength and self-capacities that undergird the ability to recognize and deal with personal insecurities, and to weather the ups and downs of all relationships, including that with the client, that offer the opportunity for the client to revise his or her insecure working model to one that is more secure. In turn, this promotes identity and self-development.” End quote.
And I would add to that, that it's also that which provides opportunity for repair. Because ruptures happen. There are ruptures in all relationships. All relationships have ruptures, even the therapeutic relationships. But healthy relationships repair them and tend to the person when a rupture happens. But if you just gloss over it, or ignore it, or dismiss it, that rupture stays there and it grows exponentially. And if it's not addressed, then it becomes more and more difficult to heal it, which becomes more and more difficult for the state of being for the client.
Courtois and Ford said, “therapists who work with this population are particularly called on to use themselves as the means of recognizing and reflecting their clients back to them through attunement, resonance and synchrony, both emotional and physical.” And that comes from Allan Schore. So if you are not accessible through the relationship, you can't develop those traits. And if you are not resonating with the client, or focused on when the client is sharing, like the client can't see what you're writing on the notepad and the client doesn't know what you're thinking about. But the client can tell when it's not about them. And the client knows when you're not focused, and survivors are particularly in tune with these issues because they are so hyper trained to predict what the caregiver is thinking or feeling because that's what kept them safe.
Courtois and Ford say, “thus, disconnection from others and self must be replaced with connection that provides positive reflection and opportunity for expanded awareness to counter construction and expanded personal and interpersonal options. The mindful therapist is one who is engaged, committed and caring, who is aware of him or herself, and how that self relates to the client to potentiate healing interactions. This dual awareness permits clients not only to feel understood and valued, but to have a role model and coach as they learn to mentalize.”
Now, this is interesting because there are some therapists that are just really not good at therapy. There are other therapists that are good at a technique, but they're really terrible at presence. And what someone needs, or when someone needs someone to be present, that is solutions, not comfort, right? And in relationships you talk about that: does this need comforted or does this need solutions? Like, are you actually asking for a brainstorming kind of fix it kind of issue? Or is this you just need me to be present in it? Some therapists, few therapists, are really, really good at being present. And that can be a powerful thing. But of those who are the best therapists and good at being present, if they're not also good at relationship, then they are going to struggle, especially with long term clients. And they have a higher risk for clients who suicide or leave treatment prematurely, Because they are not being present in the relationship itself.
So it's one thing to create a safe holding environment where clients can come and pour out these things that they need to pour out. That's important. It absolutely is. And there are some therapists that are really, really good with that. But if they are not also present in the room and tending to that relationship, then that in itself will be a rupture and it will be devastating and traumatizing in ways that are most dangerous for the client. That will liberally reenact for the client, the kind of abandonment they have already been through.
Courtois and Ford say, “therapists must also approach their work from a position of humaneness, and have a degree of humility. Although the therapist is professionally responsible for the management of the overall treatment, it is best not to approach the client from a position of being the authority on high, who has all the answers, or who will provide for all of the clients’ needs. Similarly, a narcissistic self-important therapist style involving the expectation that the client meet the needs of the therapist, rather than the other way around is a misguided one in general, but particularly with this population. It repeats what they have already experienced in primary relationships, and continues the pattern of externalization and meeting the needs of others.”
Again, instead of being able to care for their own and instead of being tended to themselves. So what does that mean when we talk about a therapist who's really good at presence, but not able to do relationship, or who needs to also do relationships to actually be safe? When we talk to survivors who have left their therapist, or when we get emails from the podcast, or when we do consultations, or when we do trainings for therapists, or have these situations when we are encountering others who like ourselves have a history of going through bad therapy, the way that they most often describe those good therapists—where they are just shocked that something went wrong—is that those therapists were good at holding presence, but not good at responding to the relationship. And in fact, sometimes use boundaries in rigid ways in effort to avoid relationships.
So this is actually something we've gotten consultation on a lot for the last year or so. Because it's something that's happened to us a lot and we don't want to repeat it for our own clients. And because recognizing what's happened helps us heal from our own ruptures even when the therapist isn't still here to participate in that repair. So it's bringing healing to us and healing to our clients. And really what it comes down to is that a therapist may be good at holding presence, but not good at being responsive. And it's being responsive that defines the relationship.
Courtois and Ford call it active stance and intentionality. They say, quote, “the inactive therapist who remains silent or who waits passively for the client to engage will more than likely be experienced as invalidating and unwelcoming or will cause the client to work hard to capture the therapist attention or approval.”
And then it goes into talking about Karpman's triangle. And how that makes the client have to rescue the therapist from their anxiety about being the therapist. Waiting to see, when the therapist is waiting to see how the client wants them to respond, then it's the client who's doing all the work and they are having to take care of the therapists instead of take care of themselves. And this is huge, because it's actually re-traumatizing. And it may happen for a long time before the client or the survivor figures out what's going on and does something about it. And what they will do about it is leave therapy, or be at very high risk for suicide, sometimes both. And that's a dangerous place for survivors to be. When people have been through relational trauma than waiting on them to initiate, or waiting passively for them to engage, feels what like they said invalidating and unwelcoming and so is going to be a huge trigger because it's acting out those same patterns of the ways that they were abused, even if the therapist is really good at presence or really good in other ways.
So a therapist can be great at holding presence when pain comes up, for example. But if they are only waiting for the client to get into that space for them to offer that service, then they're not actually helping the client navigate to that space or from that space, or tending to them in other ways. And that's exhausting on the part of the survivor.
Courtois and Ford say, quote, “The therapist must be willing to engage and be active in encouraging what is often a fearful or even terrified, mistrustful and avoided client, and must have patience and staying power whether the presentation is reluctant, resistant, evasive or fearful or avoidant, when the client shifts back and forth between being connected and disconnected, attached and detached. Or when flooding the therapist with information or when withholding. Attachment is both longed for and dreaded. Relationship closeness becomes the paradoxical trigger for danger, causing protective and proactive detachment that can upset and confused the therapist who thinks the relationship is going well, but who is unaware of the defensive use of disengagement.” This relational cycle continues until it is identified and resolved over time in a relationship that is responsive and trustworthy in an ongoing way.” End quote.
I think that this is part of what we have learned, even through friendships in the last year. The people who for their own issues, even if they're great people in lots of other ways, if they do not have capacity to be both present and responsive, they have not actually been safe people for us. And I think that we felt betrayed when people told us they were safe, but then they were not. And then we were confused when we expected them to be safe, but it didn't feel safe. And I think it took us a long time to figure out what was going on, and why it was happening, and where the danger was. Because all we knew was that it felt like something was triggered, but we didn't know what was triggered. And unfortunately that was complicated by the pandemic. And so what happened was literally a reenactment of our own abuse so that we would offer pieces of ourselves, but those pieces would not be tended to and we would not be responded to. And then we would feel shame both for having done it wrong and also for having been so foolish to try. And I think that at first we thought that it was a skill issue. That because we had not had friends before that we just needed to get better at it. And we needed to try more, like, get more practice at it. And then if we would do that. So then we are acting out our own abuse. If we can get better at it, if we can try harder, if we can do more. And so we would do more and more of those same things, of things that we thought, “Okay, this is what a friend is. And this is what a friend does. Let's show up. Let's show up.” Because that's where all the pressure was. Act like it, turn towards, step into, like all these things that were we had left off before the pandemic. And so trying to do those things in the ways we knew how. And so the harder we tried, the bigger damage was caused, when that was not responded to. We were not tended to. And the bigger the shame got for having tried so hard.
And this just was like, you know how people say in English, a downward spiral? This was like an escalating spiral. Because every time we tried harder, we failed bigger, and our shame was worse. And so that's what became toxic is we got caught in that loop. And the same thing can happen to survivors in therapy when there’s a therapist that even if they're good therapists in lots of ways, and they are really good at being present with other people's pain. And so it looks on the surface, like they're good at relationship. But they can't actually do relationship. They don't actually know how to respond to relationships, or to the conflict or to the avoidance of relationships, which is not intentional on the part of the survivor, but part of the dynamic that kept them safe when they were young. If they don't know how to stay with that, or how to be present in that, and how to respond as well, then it just leaves the client flailing alone in that shame, even while the therapist is being present.
And that's what's so high risk for suicide, and so high risk for quitting therapy. Because at some point, that becomes toxic for the client, for the survivor, to continue to engage in that pattern that is literally putting them in harm's way. And that feels so distraught and just stressful without having the relief or the help or the support in a context even of a therapist who may be supportive or helpful or present in other ways. This is huge, you guys. It's literally acting out the relational trauma without being resolved. And if the therapist doesn't change things, or the therapist doesn't call out this pattern, or the therapist doesn't respond to what's happening, it is very cruel treatment to the survivor. And it leaves the survivor in a place of despair.
Courtois and Ford talk about empathic attunement: Quote, “A psychotherapist must have the capacity to empathize. This involves extending one's personal perspective to understand that of the client even when he or she interacts in ways that are challenging, confusing, erratic or emotionally shut down. Empathic attunement is the capacity to resonate efficiently and accurately to another state of being, to match self/other understanding, to have knowledge of the internal psychological ego states of another who has suffered a trauma, and to understand the unique internal working model or schema of their trauma experience. Empathic capacity is the aptitude for empathic attunement and varies greatly among therapists working with PTSD patients.”
This is from Wilson and Thomas. They also wrote, “empathic attunement allows the therapist to decode what the client is transmitting about his or her experience in state of mind. In order to grasp the meaning of clients’ often indirect or unconscious communications, therapists must carefully follow the dynamic flow of information provided by the clients words, affects, memories, thoughts, body postures, voice modulations, expressions of personality, and here and now ego state presentations at the saliency of integrative consciousness.”
So there are so many therapists who are very good at being present, and maybe even very good at empathic attunement to where they can hold space for the client, they can be present with the client in pain, and they can handle that just fine. But if they don't also respond to that, or respond to the withdraw of that, so that they are also present in the dark side where it looks like everything is okay on the surface, or to when there's that withdraw because it's not safe to engage. If they don't stay with the client in those more invisible moments… Then what it does is set up the therapist in being the hero role or the rescuer role where the therapist becomes known for, but not actually present in, showing up for people's pain. So they're good at showing up. And they're good at being there. And they're good at being present in it, but not tending to it or responding to it, which just feels cold and neglectful, and triggering of all of that abandonment when things were not tended to in the past. And in many cases, can act out that scenario where then the therapist becomes like the complicit parent. Where a parent was aware that another parent was abusing the child. And maybe they didn't participate in the abuse, but they were present there without stopping it or they were present there without tending to the child, and that can be soul triggering as well.
Courtois and Ford said, “Empathic strain results from those interpersonal events in psychotherapy that weaken, injure, or force beyond reasonable limits the therapeutic response to the client. Countertransference processes are only one source of empathic strain. Yet we believe that in the treatment of PTSD countertransference responses are perhaps the primary cause of treatment failure.”
This conversation will be continued in the next episode. Thank you for listening.
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Thank you for joining us for System Speak – a podcast about dissociative identity disorder. This podcast is available on any podcast player and on systemspeak.org. If you would like to know more of our story, our memoir, If Tears Were Prayers, is now available at systemspeakbooks.com. Thank you for listening.