Bringing Families into Trauma Treatment
By Mary Jo Barrett
The clients I saw in my practice last week were typical of my ordinary caseload. There were couples in violent relationships, an internist who’d sexually abused patients and nurses, an agitated combat veteran just returned from Afghanistan, and a woman who’s spent nearly 20 years cut off from her family and friends because her abusive and jealous spouse keeps her completely isolated. There were also clients whose traumas were less obvious and dramatic but still shaping the way they handled the stresses and conflicts in their present lives. Whatever the differences in presenting symptoms, the common thread in almost all the cases I see is a legacy of complex trauma as a result of relational violence or severe neglect within a family.
Such cases have been the focus of my work over the past 35 years, a period in which the trauma field has seen the emergence of powerful therapeutic innovations like eye movement desensitization and reprocessing, Somatic Experiencing, dialectical behavior therapy, and Internal Family Systems, as well as many major advances in our understanding of the brain and the neurobiology of trauma. Clearly, we’ve made important strides in our ability to help overwhelmed and hopeless people overcome the stigma previously attached to trauma symptoms, learn new thinking and self-regulation skills, and even find a new sense of restored well-being—at least for the period of time that they’re with us in our offices.
But then they go home, and far more often than we’d like, when they’re back in their daily lives with family, friends, and coworkers, they don’t do so well. In fact, no matter what progress they make in therapy, once they leave the safe, rarified space we provide them in our treatment rooms, they frequently fall right back into the same old patterns of negative emotion and dysfunctional relationships.
Let me give you an example. Lucy, a therapist I supervise, recently came in to discuss a difficult case. Her client, Abbey, a 46-year-old woman, suffers from severe anxiety and depression, abuses prescription drugs, purposely harms herself by hitting herself all over her body and head, frequently quits or is fired from jobs, and regularly alienates the few friends she has. Like many trauma sufferers, she’s easily triggered by her interactions with just about everybody she knows, especially her husband and two teenage children, who she says are “miserable, nasty human beings.” At home, she fluctuates between furiously attacking them—yelling hateful remarks, throwing things—and withdrawing into a sullen shell.
During sessions, Abbey dissociates while talking about her life, past or present. But through Lucy’s guidance and skill, she’s learned and practices many mindfulness techniques that have enhanced her ability to recover and bring herself back into her body when she shuts down. Most days when Abbey leaves therapy, she’s calmer, exhibits some genuine insights into herself and her problems, and often seems to be discovering an embryonic, but real, sense of inner selfhood. By the next session, however, it’s as if she has amnesia for all that transpired in the previous week. So she routinely begins each session, week after week, in varying states of anger, despair, dissociation, hyperanxiety, or rock-bottom depression.
By any measure, Lucy is an accomplished, well-trained therapist, proficient in integrating a range of therapies into her practice. And Abbey is a willing client: she meditates daily, takes the appropriate medications, cooperates fully in sessions, and practices many of the skills Lucy has taught her. Apparently, Abbey likes Lucy very much, and the two have a warm, mutually trusting working relationship—but the therapy is still stuck.
“Help!” Lucy said to me during our consultation. “I don’t know what else to do. Why isn’t she getting better in her outside life?”
Most clinicians believe that the benefits of individual therapy should naturally transfer to the rest of a client’s life. But what if that’s not necessarily true? What if the positive interactions a person has with a therapist in the “inside” world of the consulting room don’t translate into the language of relationships conducted in the “outside” world of the person’s everyday life?
In therapy, clients feel—often for the first time—truly seen, heard, and understood. It’s no wonder they might think, with a sparkle in their eye, that if only their therapist was their spouse (or parent or friend or child), their lives would instantly be better. It’s no wonder they might scream in the middle of a fight at home, “Well, at least my therapist understands me!” So why are we surprised when real-life spouses, parents, friends, or children begin to see us—the all-loving therapists—as threats to the marriage, the family, the friendship? After all, therapists—yes, me included—can unwittingly play into this ultimately damaging process.