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Putting the Pieces Together

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PNMA14-3

25 Years of Learning Trauma Treatment

By Janina Fisher

I now realize that back in 1989, when I began my clinical internship in a big city hospital, most of our patients—everyone from university professors to working-class families to the homeless and chronically mentally ill—were suffering the effects of some unrecognized traumatic experience. I say unrecognized because, back then, we connected the word trauma only to combat veterans and victims of sexual violence. It was 15 years since the opening of the first rape crisis center, and just nine since post-traumatic stress disorder (PTSD) had become an officially recognized DSM diagnosis. Trauma, in fact, was still defined as “an event outside the range of normal human experience.” We didn’t yet know to ask all clients about early abuse or trauma, and we unconditionally accepted the idea that uncovering buried memories was the key to setting trauma sufferers free. As descendants of Freud, we believed that the therapist’s role was to remain neutral and say as little as possible while the patient free-associated until the time came for the right interpretation or the always handy question, “How do you feel about that?”

By the early 1990s, however, The Courage to Heal, a feminist-influenced self-help book by Ellen Bass and Laura Davis, had become a bestseller. Bringing public attention to the previously taboo subject of childhood sexual abuse, it proposed a dramatic approach to trauma treatment, one that was a far cry from the strict neutrality prescribed by psychoanalysis. In essence, Bass and Davis saw the main task of trauma work as retrieving the missing pieces of the abuse narrative, however dimly it might be recalled, and encouraging victims to confront their perpetrators with “their truth.” As a fledgling therapist who’d never felt comfortable just nodding sympathetically in response to someone’s horrible tale of a trauma experience, I was relieved by the permission this approach gave me to engage my clients more actively.

At the same time, I was troubled by what the The Courage to Heal model required of my clients: focusing on accessing their anger at the perpetrators or neglectful bystanders and holding them accountable through confrontation. Most therapists applauded the way this model encouraged survivors to become more vocal and empowered, but at the hospital where I worked, we were seeing some dangerous effects of this approach. Many clients became overwhelmed by the flood of memories that came once Pandora’s box was opened, and others began to doubt themselves when they couldn’t access memories. Worse yet, family confrontations frequently ended in retraumatization for the victim. Many family members refused to believe the disclosures, and even turned the tables on survivors by accusing them of destroying the family. Rather than finding support, our clients often found themselves becoming family outcasts.

During this paradigm shift in the trauma-treatment world, Judith Herman, who’d published Father-Daughter Incest in 1980, was working as a staff psychiatrist at Cambridge Hospital in Massachusetts and establishing a special clinic called the Victims of Violence Program. In the broader mental health world, few people knew of her book, her clinic, or the research she’d begun on the relationship between borderline personality and childhood abuse. Even after the release of her groundbreaking Trauma and Recovery in 1992, it would take several years for her ideas to catch on.

Still, she was convinced that there was something deeply amiss and destabilizing about the confrontational tactics recommended by Bass and Davis. She believed that good trauma treatment required a much more patient approach—delaying the focus on traumatic memories until survivors felt safe in their daily lives and had sufficient affect regulation to tolerate the stress of remembering dark episodes in their histories. A political feminist, she argued that victims needed to feel empowered in their relationships not only with their peers and partners, but also with their own memories. To her, the idea of feeling overwhelmed and overpowered by the remembering process was antithetical to the resolution of trauma. Although today the word retraumatization is used routinely by mental health professionals and stabilization first has become the gold standard of trauma treatment, these were new ideas at the time.

Also new was Herman’s insistence that the power imbalance of the therapeutic relationship was exacerbated by therapists’ keeping to themselves the growing literature about PTSD, its treatment, and the course of recovery. She believed that therapists must become educators, providing information that made sense of the client’s symptoms and helping them understand their intense reactions as survival adaptations to a dangerous and coercive childhood environment. Her idea that knowledge is power resonated deeply with me, as did her view, which was contrary to Bass and Davis’s model, that premature memory retrieval and disclosure could be harmful to many clients. Telling their stories of abuse was emboldening only when they could tolerate the overwhelming feelings that this process was likely to trigger; and confronting families, if it ever took place, could wait until they no longer needed anything from them.

Just how revolutionary the idea of stabilization was in the early 1990s is illustrated by my meeting with a young client named Ariana. Despite a long history of childhood sexual abuse and many attempts to get help, she hadn’t been able to tolerate therapy for more than a few months. Since she seemed to be the ideal therapy client—bright, insightful, and articulate—I was curious about why this was so.

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3 comments

  • Comment Link Wednesday, 28 May 2014 12:58 posted by Fred Stephens

    Excellent article with a nice balance of history and treatment antidotes. I work with Appalachian traumatized kids in long term residential treatment. I will make immediate use of what I have learned from Ms. Fisher. Fortunately I learned quickly when I started this work that my academic training about healing PTSD was not applicable to my patients. I was introduced to the term \"complex trauma\" after graduating in 2011. TF-CBT is useless if not damaging most of the time! Sad state of academic training?

    I appreciate Ms. Fisher\'s suggestions of what to look for and what to say. Despite all said about \"busting\" talk therapy, we rely (not solely) on a finely tuned talk dialogue. Only with her suggestions we are putting more attention to mindfulness and reducing noise.God and the devil are in the details. Ms. Fisher gives us fine details reduced noise in her writing style.

    However, I want to contribute a general critique. More references would be helpful. For example, when you (Ms. Fisher) mention van der Kolk\'s 1994 study, it would be nice to have a reference.

    This is a criticism of the magazine in general: too few references. In this case, I could probably find the 1994 study/paper. However, some Networker authors make important assertions without readers having any clue as to where the \"fact\" comes from. I am thinking about recent gender related writings were emotional bias appears to overcome solid writing. For a professional magazine, the Networker slips too often into this reference free zone.

  • Comment Link Tuesday, 27 May 2014 13:00 posted by Sachelle Le Gall

    This article provides such a context into the evolution of trauma treatment with case examples that helps to translate the discoveries of neuroscience and how it can be applied to clinical practice. Thank you for this Janina.

  • Comment Link Tuesday, 13 May 2014 16:38 posted by Zyg Kaminski

    My compliments on a very clear and concise account of a very difficult area.