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by Susan Rowan
I doubt that I would fit many people's image of a therapist who would violate sexual boundaries with a client. Before it happened, I certainly did not fit my own. On the day I first met Cara, I was a well-respected social worker at a venerable psychiatric hospital in the Midwest. I viewed myself as a caring and conscientious professional. Yet, over the course of two years, I progressed from sympathizing with Cara, to over-sympathizing with her, buying her groceries, paying her rent and, finally, sleeping with her. At first, I did not think I was doing anything harmful--I was going the extra mile, helping Cara until she could take care of herself. But my previous dedication to all my clients became an obsession with one.
It was as though I were skiing down a steep mountain in what seemed to be deep, safe snow. Blinded by arrogance, I traversed back and forth, each time taking a little more risk. There were unknown moguls under the surface and, as my speed picked up, I totally lost control of my skis.
Starting Down the Slope
Therapy began routinely enough in the summer of 1993. Cara, the attractive mother of young, twin boys, had been hospitalized following the latest in a series of suicide attempts and self-mutilations. She and her husband were assigned to me during her hospitalization for marital therapy. Despite her troubles, I found her to be bright, sensitive and a talented visual artist. Subjected to severe physical abuse as a child, Cara had been given the diagnosis of Dissociative Identity Disorder, and her childlike alter-personalities and novel diagnosis intrigued me. I extended our meeting times in preparation for her marital sessions and took long walks with her on the hospital grounds. Overwhelmed by feelings of protectiveness, I doubted the competence of hospital staff to prevent her ingenious attempts to harm herself.
After four months of marital therapy, Cara's husband discovered she had had an affair before her hospitalization and, at his insistence, their marriage ended. Soon afterward, Cara was discharged. My job was now officially over: it required me only to provide short-term family therapy until a patient's discharge. But then, Cara called me at my hospital office a week later to discuss a personal problem, and in one of my first major boundary slips, I took her call.
Why did I encourage this first, seemingly minor, deviation from good clinical practice? I was vulnerable, ignorant, arrogant and lonely. I'd recently ended a 10-year relationship with another woman--a relationship so intimate that we'd both worn wedding bands. Depressed, numb and disconnected, I was drinking alone at night. My work provided me with my only emotional sustenance, and it, too, had become a dark and confusing place. It was the early 1990s, and our inpatient unit was fast becoming a world of its own--we were fascinated with childhood trauma and Multiple Personality Disorder, and convinced that other clinicians did not understand these clients. I spent many daylight hours listening to patients describe horrifying abuse, and at night I had nightmares of young children who were being sodomized.
At the same time, I was becoming isolated from the norms of my profession: I left my family therapy supervisor and began working under a charismatic psychiatrist who specialized in trauma. As a family therapist and a social worker, I'd been taught to pooh-pooh psychodynamic notions like transference and countertransference. I had never even taken a course in professional ethics or the need for boundaries. Over dinner one night, my new supervisor confessed to me that he was having an affair with one of his clients, and told me of the many founders of psychoanalysis (including Carl Jung, Otto Rank, Frieda Fromm-Reichmann, Fritz Perls and SaÂ´ndor Ferenczi) who had also had such affairs. The stage was set for me to do so as well.
Not long afterward, I gave Cara my beeper number, and within a couple of months, we were talking on the phone almost daily. I rationalized we were becoming friends. It was an odd sort of friendship.
One day, she called me in distress, saying she had no money to feed her sons. I called the department of social services on her behalf, rationalizing that I was merely being her advocate. A month later, after an alarming, drugged-sounding call from her, I drove to her home and found her lying in a pool of blood, having severely cut herself. I called the ambulance and stayed behind to clean up her blood, hoping to protect her young twins from trauma when they returned home from daycare.
Again, I ignored my violations of clinical boundaries--boundaries as much for my own protection as for hers. I was skiing out of control. A few weeks later, Cara asked me for money for groceries. Uncomfortable with giving her money, I took a shopping list from her, went to her house with five full shopping bags and helped her stack her shelves and refrigerator, gratified by her effusive thanks. Next, she asked for rent money, and then for help with her gas and electric bill. I paid them both, and she told me she didn't know what she'd do without me.
Why on earth did I do it? I've spent years since then examining the risk factors that led me to destroy my professional career. Part of the explanation lies in personal vulnerabilities my previous training never encouraged me to explore. (I had never been in therapy myself.) My own mother had been seriously ill with rheumatic heart disease throughout my childhood, and had died when I was 18. A sister 20 years older than I had been my surrogate mother and had paid for my college and graduate school. As I stacked Cara's groceries that day, I rationalized that I was helping her and her children--as my sister had helped me--just until she could function on her own. I was dead wrong.
As my financial support increased, Cara put more and more effort into getting my help, and had less and less into working on her own behalf. She reinforced my behavior by sending me beautiful pictures she had drawn. We exchanged letters, discussing our most intimate thoughts about society, people and relationships. We lunched, played tennis, even took an art class together. Just before her twins began kindergarten, I helped her to find a new apartment in a better school district and paid the increased rent. Instead of developing confidence in her ability to run her own life, she was developing a pathological dependence on me.
I found myself more and more attracted to her. She had a pleasing way of interacting with others and could be, in some ways, seductive. Sometimes, after drinking heavily, I made clumsy attempts to tell her that I thought I was falling in love with her. Several times, we kissed each other, and one evening we went into her bedroom together and lay close with our clothes on.
Over the next month, we had a few tentative sexual encounters. After each one, I felt disgusted and upset with myself. (Far gone as I was, I knew it was not okay to sleep with clients, former or otherwise.) One night, I told her my feelings. She responded sensitively and empathically. We agreed to remain friends but to stop being physically intimate.
That did not mean the end of our mutually dependent and increasingly destructive relationship. Just because I was drawing back, Cara did not magically develop the autonomy and self-confidence she had originally sought through therapy. I drove her to difficult therapy sessions and babysat her twins when she was away. What had begun as a request for a few hundred dollars mushroomed into demands that totaled $40,000 before the end of our relationship.
As she became more desperate and demanding, I became more miserable. I stopped returning her increasingly angry phone calls. She finally left a message on my answering machine telling me that she could ruin me.
Finally, depressed and on the edge of financial collapse, I told her that I was going to end all contact and financial support on a set date two months hence. When the date came, she was back in the hospital and reported our sexual relationship to the hospital authorities. When they asked me, I told the truth. I could not fight anymore.
I lost my job. My clinical reputation was destroyed and my license was revoked for two years pending rehabilitation. Cara sued me and I had to declare bankruptcy. I lost a promising career spanning more than 20 years, as well as the respect of many friends at my beloved hospital.
Since that day seven years ago, I have been fortunate enough to be allowed to return to practice. I passed a forensic evaluation and my licensing board has reinstated me, under strict conditions that include having a mentor (a specialist in transference and countertransference) to oversee my clinical work. I've undergone prolonged retraining, including an individual ethics tutorial. I've studied the professional literature on ethics violations and have been educated in the need for boundaries. The lawsuit was settled by my insurance carrier and I stopped drinking. As a condition of my license reinstatement, I am required to undergo psychotherapy until my therapist and I feel I don't need to any longer--at least another two or three years.
I realize that some therapists reading this may feel sympathetic toward me--that I tangled naively with the sort of boundary-less client that we're frequently warned against. But the responsibility lies with me. It was my responsibility, not hers, to know my profession's norms and to preserve clinical boundaries. It was my responsibility to understand that power between a client and a therapist is never equal and that a so-called friendship is never appropriate after clinical work. It doesn't matter how provocative, vulnerable or seductive a client is. It is my responsibility not to create pathological dependencies.
I still find it difficult to reconcile the fact that I was so destructive to Cara's life, when I intended to be so helpful. Yet, morally, I am left with the consequences of my actions. After our relationship, Cara continued to cut herself and had even less confidence in herself and in the possibility that our profession could help her. I do not believe there can be a harsher critic of me than I am.
I work now in a community mental health clinic at about half the pay I used to receive. Every day, I try to be aware of any sign that I could be taking a first step down that slippery slope. Recently, on a windy day, a poor client asked me for busfare home. It seemed like a simple request, one that I could easily honor. I said no.
"Susan Rowan" is the pseudonym of an experienced licensed clinical social worker in her mid-forties. She works with the severely mentally ill in a community mental health center.
Red Flags Signaling Loss of Control
I have chosen to write my story, in part, so that others could learn from my mistakes. I hope I have learned from them. I will forever be aware of the warning signs that signal a loss of control. Below is a list of "red flags," distilled from the clinical literature and my own experience, that I hope will help other therapists stay off the slippery slope.
- Specialness . A belief that this particular client, therapist or situation is somehow "special" and the ordinary rules don't apply.
- Attraction. Intense attraction of any kind, including: fascination with a particular diagnosis; excessive time worrying about the client; sexual, romantic or rescue fantasies; excessive pity or admiration.
- In-Session Behavior Changes. Spending more time together than is clinically appropriate. Excessive self-disclosure and poor impulse control by the therapist. Being unable to say no to the client.
- Violating Clinical Norms. Changing normal routines: seeing a client outside the office; excessive gift-giving or receiving; giving money; reducing fees inappropriately.
- Professional Isolation. Neglecting outside interests. Professional and personal isolation. Concealing the situation from colleagues.
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by Babette Rothschild
Much as we don't like to admit it publicly, it's an open secret among therapists that the road to recovery from trauma can be fraught with clinical missteps. In the past few years, I've frequently been consulted by highly competent colleagues who were dumbfounded by the speedy decline of clients contending with traumatic memories.
Eight of these clients included a nurse, a businesswoman, a salesman, a therapist, and other men and women who'd functioned relatively well prior to therapy. Yet after attempts to address their traumatic pasts (including rape, mugging, childhood abuse, and household fire), three were hospitalized, two went on disability, and the rest endured debilitating flashbacks, panic attacks, or other symptoms of dysfunction.
All the therapists involved were experienced and well trained. Each one favored a different, theoretically sound, therapeutic modality (psychodynamic psychotherapy, EMDR, body psychotherapy, and cognitive-behavioral). None was irresponsible. So what exactly went wrong?
In each instance, I eventually discovered, traumatic material was addressed before the client was equipped to manage it. These therapists were proceeding in a manner consistent with the usual aim of psychotherapy: helping a client open up. They knew very well how to call the genie of traumatic experience out of the bottle, but as is all too common, they didn't know how to get the genie back in.
My approach to trauma work, which is more cautious, is rooted in an experience I had in college. A friend asked me to teach her to drive--in a new car my father had just given me. Sitting in the passenger seat next to her as she prepared to turn on the ignition, I suddenly panicked. I quickly realized that before I taught her how to make that powerful machine go, I had to make sure that she knew how to put on the brakes.
I apply the same principle to therapy, especially trauma therapy. I never help clients call forth traumatic memories unless I and my clients are confident that the flow of their anxiety, emotion, memories, and body sensations can be contained at will. I never teach a client to hit the accelerator, in other words, before I know that he can find the brake.
Following this principle not only makes trauma therapy safer and easier to control, it also gives clients more courage as they approach this daunting material. Once they know they're in the driver's seat and can stop the flow of distress at any time, they can dare to go deeper. Developing "trauma brakes" makes it possible for clients, often for the first time, to have control over their traumatic memories, rather than feeling controlled by them.
My client Paula, for instance, first came to see me for problems in her marriage. She was in her mid-thirties and had three children under the age of 10. When she was a child, her mother had sometimes harshly beaten her. Paula still lived in fear of her mother's aggression, although now it took the form of yelling and criticism, rather than physical violence.
One morning, Paula came into her session pale, with her head bowed. Hardly looking up at me, she moved to her chair and crouched in it, shaking. I'd later learn that she'd just finished a searing telephone conversation with her mother.
Asking Paula about the source of her distress first thing would have let the genie of her traumatic past out of the bottle, increasing her distress. First I needed to help her calm down, to put her in charge of her somatic and emotional responses.
"You're really shaking, aren't you?" I said, drawing her attention to her body sensations. Sometimes this type of intervention is enough to help a client calm down, though for Paula it wasn't. "Y-y-ye-s," she replied with difficulty. "I s-sometimes s- shake a lot." A few seconds later, she was no longer able to speak and could only show me how fast her heart was beating by a rapid movement of her hand.
Paula was exhibiting symptoms of what neuroscientists call hyperarousal--a flood of adrenaline and other stress hormones that made her feel threatened and confused. The brain structures most involved in rational thought and memory were, practically speaking, out of commission. In neurophysiological terms, her sympathetic nervous system (which responds to situations of danger, threat, and stress) was in overdrive, giving her a pounding heart, a dry mouth, and muscle tremors.
To help a client when she comes as unglued as Paula was that day, it's useful to understand what's currently known about how the brain handles danger and emotion, especially in the limbic system and two of its major structures: the hippocampus and the amygdala.
The limbic system is survival central, the area of the mid-brain that initiates fight, flight, or freeze responses in the face of threat. (Paula was on the verge of freezing.) The amygdala and the hippocampus, part of the limbic system, are also deeply involved in responding to traumatic events.
The cortex, the more rational, outermost layer of the brain, is the seat of our thinking capacity and our ability to judge, deliberate, contrast, and compare. It's where most memory--traumatic and otherwise--is stored. The cool, rational cortex is in constant communication with the amygdala and the hippocampus.
The Early-Warning System
The amygdala is our early-warning system. It processes emotion before the cortex even gets the message that something has happened. When you smile at the sight or sound of someone you love even before you consciously recognize her, for instance, the amygdala is at work. Here's what happens: the sound of the loved one's voice is communicated to the amygdala via exteroceptive auditory nerves in the sensory nervous system. The amygdala then generates an emotional response to that information (pleasure or happiness, in this example) by releasing hormones that stimulate the visceral muscles of the autonomic nervous system and can be felt as pleasant sensations in the stomach and elsewhere. Lastly, the amygdala sets in motion an accompanying somatic nervous system (skeletal-muscle) response, in this case, tensing muscles at the sides of the mouth into a smile.
A similar process occurs with other types of stimuli, including trauma. When someone is threatened, the amygdala perceives danger through the exteroceptive senses (sight, hearing, touch, taste and/or smell) and sets in motion the series of hormone releases and other somatic reactions that quickly lead to the defensive responses of fight, flight, and freeze. Adrenaline stops digestive processes (hence the dry mouth) and increases heart rate and respiration to quickly increase oxygenation of the muscles necessary to meet the demands of self-defense.
The amygdala is immune to the effect of stress hormones and may even continue to sound an alarm inappropriately. In fact, that could be said to be the core of post-traumatic stress disorder (PTSD)--the amygdala's perpetuating alarms even after the actual danger has ceased. Unimpeded, the amygdala stimulates the same hormonal release as during actual threat, which leads to the same responses: preparation for fight, flight, or--as with Paula--freeze. In PTSD, this happens regularly, despite outward evidence that these responses are no longer needed. In sum, PTSD could be said to be a healthy survival response gone amok.
Why does the amygdala continue to perceive danger? What makes it possible for the whole body to repeatedly respond as if there is danger, when in fact the danger is past?
The Rational System
The hippocampus helps to process information and lends time and spatial context to memories of events. How well it functions determines the difference between normal and dysfunctional responses to trauma and normal versus traumatic memory. An example will help to explain.
In his book The Emotional Brain, Joseph LeDoux explains the survival response involved when encountering an object that looks like a snake. Naturally, the amygdala signals an alarm message, which sets in motion a series of reactions that culminate in the footstep halting in midair. The amygdala's communication travels at lightning speed. There's a second communication pathway that takes longer, eventually getting the message around to the cortex, where rational thought takes place. When the information "It's a snake!" reaches the cortex, it's then possible to evaluate the accuracy of the amygdala's perception. If the message was accurate and it is a snake, the halted step will freeze until the danger is passed, i.e., the snake slithers away. If, however, there's a discrepancy and what was thought to be a snake is discerned by the cortex to be a bent piece of wood, the cortex sends a new message to the amygdala, "Hey, it's only a stick," to stop the alarm immediately.
The hippocampus assists the transfer of the initial information--the image of stick or snake--to the cortex, where it's then possible to make sense of the situation. This is the normal way information is communicated, as long as the hippocampus is able to function.
The hippocampus, however, is highly vulnerable to stress hormones, particularly adrenaline and noradrenaline, released by the amygdala's alarm. When those hormones reach a high level, they suppress the activity of the hippocampus and it loses its ability to function. Information that could make it possible to determine the difference between a snake and a stick (or, as in Paula's case, past danger and current safety) never reaches the cortex, and a rational evaluation of the situation isn't possible.
The hippocampus is also a key structure in facilitating resolution and integration of traumatic incidents and traumatic memory. It inscribes time context on events, giving each of them a beginning, middle, and--most important with regard to traumatic memory--an end. A well-functioning hippocampus makes it possible for the cortex to recognize when a trauma is over, perhaps even long past. Then it instructs the amygdala to stop sounding an alarm.
This has critical implications for therapy. Safe, successful trauma therapy must maintain stress hormone levels low enough to keep the hippocampus functioning. That's why it's so crucial for both client and therapist to know how to "apply the brakes" in therapy--to keep the hippocampus in commission and return it to action as promptly as possible when the system goes on overload.
When and How to Apply the Brakes
Knowing when to apply the brakes is as important as knowing how . Therapists can know when by watching for physical signals of autonomic system arousal, transmitted by the client's body, tone of voice, and physical movements. When a client turns pale, breathes in fast, panting breaths, has dilated pupils, and shivers or feels cold, her sympathetic nervous system (activated in states of stress) is aroused. Stress hormones are pouring into her body, threatening the hippocampus with shut-down. These symptoms mean it's time to calm the client down.
When, on the other hand, a client sighs, breathes more slowly, sobs deeply, sweats, or flushes, her parasympathetic nervous system (activated in states of rest and relaxation) has been activated, and her stress hormone levels are reducing. Recognizing these bodily signals is invaluable to the therapist. Likewise, a client who learns to recognize them often gains a greater sense of body awareness and self-control.
After identifying Paula's hyperaroused state, I asked her a few specific questions to narrow her focus. For some clients, paying attention to body sensations helps put on the brakes, but that wasn't the case with Paula, as I quickly found out. Her continued hyperarousal told me that her amygdala persisted in assessing danger. I needed to find another way to help her evaluate this situation, in this room with me.
I decided to see if I could directly engage her cortex using what I call dual awareness. If I could help her to accurately see where she was and whom she was with, she might be able to calm down. So I asked her, "Can you see me?" She replied with a nod of the head. "Clearly?" I could see her breathing slow a little and she managed to say, "Yes."
As Paula's arousal lessened, I asked for more information. "Tell me what you see. Describe me: What color are my eyes? What color is my hair? Am I having a good hair day or a bad hair day?"
Breathing slightly easier, Paula was now able to reply, "Your eyes and hair are brown. I think you're having a good hair day." We both laughed a little; laughter is great for calming the nervous system. I could see color returning to her face and she was shaking less.
To increase her body awareness and the connection between what we were doing and her emotional state, I asked, Paula to describe what happened to her shaking as she looked at and described me.
"It's less," she realized. But she was still shaking a bit, so we weren't through. On a hunch I asked if she felt threatened by me in any way.
"No," she said, "but don't come closer."
Her reply gave me a big clue. "Perhaps," I ventured, "I'm actually sitting too close to you. I'd like to try moving back a little. Would that be okay?"
She wanted me to move back a foot. When I complied, she exhaled sharply. I drew her attention to that response as well as another. "Something else changed. Do you know what?"
"I stopped shaking."
At this point Paula was much calmer, visibly to me and noticeably to her. Her cortex was beginning to discern that she was in a safe place, with a person who wouldn't harm her. It seemed that increasing the distance between us was useful for her, and I asked if she wanted to try increasing it more.
This time, she was more assertive, asking me to move back two feet. Then she was aware of physiological changes even before I asked. "I can breathe easier," she said. She also told me that her heart rate was much slower, nearly normal. But she complained that her legs felt rather weak, which is a common consequence of fear--that feeling of being "weak in the knees."
Increasing strength in her legs could help her feel more secure, so I instructed her to put weight on her feet and press them into the floor. "Do it as if you're going to tip your chair back, but don't actually do that. The point is to increase the tone in your thighs. When they begin to get tired, release the tension very, very slowly." That would insure that some of the tone remained.
As her thighs became stronger, Paula felt even calmer, and was able to think clearly. Her hippocampus was functioning now that stress hormones were no longer being released. To facilitate integration I asked, "What have you learned in the last few minutes since you arrived?" I wanted her to know what had helped, so she'd be able to use some of these same tools to combat hyperarousal and anxiety in her daily life.
Paula easily identified that she felt calmer when I sat farther away and that it was helpful when I asked her to describe me. "Looking at you, I stopped thinking about my mother. Just before I came, we had a big fight."
It became obvious to both of us that in her hyperaroused state, Paula had entered the session expecting me to act like her mother. "Actually, I expect everybody to act like her," she said.
That insight laid the groundwork for the rest of the session, in which we focused on helping Paula to differentiate who was a person to fear and who wasn't. That work wouldn't have been possible at the beginning of the session, when her hippocampus was overwhelmed.
Had I immediately begun questioning Paula on the causes of her distress instead of first attending to putting on the brakes, her overwhelmed hippocampus would have made it difficult for her to clearly separate me from her mother, and together we might have wandered into one of those anguished quagmires well known to trauma therapists. Putting on the brakes helped to avoid a potential transference disaster.
There's a common misconception among many trauma survivors and trauma therapists that working in states of high distress, including flashbacks, is the way to resolve traumatic memories. But being in the throes of hyperarousal and flashback indicates that the hippocampus isn't available to distinguish past from present, danger from safety. Under those conditions, working with traumatic images and the emotions they engender can risk a variety of negative experiences. Moreover, as Judith Herman has said, a trauma survivor's primary need is to feel safe, particularly in therapy. Applying the brakes to keep arousal low and the hippocampus functioning makes this goal much easier to achieve.
Babette Rothschild, M.S.W., L.C.S.W., is in private practice in Los Angeles. She's the author of The Body Remembers: The Psychophysiology of Trauma & Trauma Treatment , and the forthcoming The Body Remembers Casebook: Unifying Methods and Models in the Treatment of Trauma and PTSD . Address: P.O. Box 241783, Los Angeles, CA 90024. E-mails to the author can be sent to: firstname.lastname@example.org.
Damasio, Antonio R. Descartes' Error: Emotion, Reason, and the Human Brain New York: Putnam's Sons, 1994.
Herman, Judith L. Trauma and Recovery. New York: Basic Books, 1997.
Nadel, L., & Jacobs, W.J. "The Role of the Hippocampus in PTSD, Panic, and Phobia." In Nobumasa Kato, ed. Hippocampus: Functions and Clinical Relevance. Amsterdam: Elsevier, 1996.
van der Kolk, Bessel A., Alexander C. McFarlane, and Lars Weisaeth, eds. Traumatic Stress. New York: Guilford, 1996.
by Linda Stone Fish
I live in a small city in Upstate New York, and most people in town know somebody who knows me, my husband (a clinical psychologist) or one of our four engaged and energetic sons. My husband and I are both active in our town's small Jewish community and have private practices; I teach family therapy at the local university; and all of our sons are heavily involved in athletics, drama and school social life. So it's no wonder that I sometimes cross paths with my clients in town--if not at the supermarket, then on the athletic field, at the hairdresser's or at temple.
Despite all this, I managed, for two decades, to maintain (in my own mind, at least) a fire wall between my personal and professional lives. In the consulting room and the classroom, I worked to present an air of calm worldliness, an expert with the answers to all sorts of painful therapeutic and family dilemmas. I was at pains not to look like someone who would lose it with her kids or yell or scream--which is precisely what I sometimes did when I got home to a house full of hungry boys ranging in age from 4 to 16.
Then, late one spring afternoon four years ago, I walked into Wegman's, the huge supermarket on the east side of Syracuse. (It's the kind of place with a dry cleaner and a cafe as well as acres of gorgeous fruits, breads and vegetables.) With me was my youngest son: 4 years old, tired and whiny. I'd been teaching and seeing clients all day. There was nothing in the house for dinner. I was having babysitter problems and I was due at another son's baseball game in less than an hour. In short, I was fried.
Near the yellow and red peppers, I pried a shopping cart loose and asked--or rather told--my son to get in. He refused. In no mood to fool around or cajole, I grabbed him by the shoulders, lifted him up and tried to force him into the cart. He stiffened and began screaming.
It was one of those moments when other shoppers look over and think, That is the worst mother in the world. That poor child! I wanted to yell at my son at the top of my lungs or just leave him screaming on the floor while I shopped, but instead I managed to bend his legs into the cart and wheel him forward, still screaming. I was picking up hamburger buns when, out of the corner of my eye, I saw Jan, one of my most recent clients. She was staring at me, and she wasn't the only one.
I did the only thing a professional could do under such circumstances--I pretended she did not exist, kept my eyes straight ahead and wheeled my screaming child toward the meat section while acting as though I was on a cruise drinking pina coladas.
Jan (now thankfully out of my sight) had become my client six weeks earlier because she was exhausted and overwhelmed by her 13-year-old daughter, who was doing poorly in school and behaving badly at home. We were at an impasse: Jan wanted me, the expert, to see her daughter individually and straighten everything out. I was insisting on seeing mother and daughter together and was (so far unsuccessfully) encouraging Jan to do homework that involved connecting with her daughter while setting limits.
Or at least, that was the role I was trying to play with Jan, until the moment she saw me push a screaming child around the supermarket in a controlled frenzy, picking up milk, hamburger, frozen french fries and a bag of lettuce greens. In the car on the way home, with my son still screaming, I, literally, had fantasies of closing my private practice and getting a job at K-Mart.
All that week, I waited for the call canceling Jan's next session and letting me know what a joke I was. But on Friday at 4:30, Jan appeared with her daughter Sarah to tell me that, for the first time, she (Jan) had done the homework I had given her. (I had asked her to stand up to her daughter and make sure she did a schoolwork assignment, even if Sarah tried to distract her by being mean.) Jan had also made an appointment with a school administrator to get an evaluation of her daughter's learning problems. Her passivity had disappeared.
"Linda, I hear what you have been saying," Jan said. "I needed to do something different and I was resisting it!"
"I'm so impressed!" I said, leaning happily back in my chair, figuring that the woman in the supermarket must have just been a Jan look-alike.
"Seeing you in the grocery store really had an impact on me," Jan said. "Boy, do you have your hands full!"
I reminded myself to breathe.
"You were a myth to me," Jan went on. "You had it all together. How could you understand how overwhelmed I felt? Then, I saw that you, too, are overwhelmed, but you just keep putting one foot in front of the other. I can't tell you how empowering it was."
My face turned bright red in the presence of truth. I had been caught being myself. Jan was being helped not by my fake professional calm, but my humanness.
After that, I came to a decision to consciously bring some of the wisdom and skill of my profession into my life with my children and husband at home. And I started bringing into the office the honesty and imperfection I had once tried to sequester in my personal life. Nowadays, I'm much more likely to tell a client that a teacher once told me how much she hated one of my boys, for instance, or that another son still does something with his shoulders that I think makes him look retarded and I sometimes yell at him to get out of the room.
I still think back on the moment Jan saw me in the grocery store, and I continue to be freed by it. In my office, I no longer work so hard to project tightly wound calm. Clients who haven't seen me in a while sometimes comment on how much more relaxed I seem. And I do feel less tense, having stumbled onto an old truth: it is me, not the image of professionalism I once thought I was conveying, that people find helpful and healing .
Linda Stone Fish is a professor, chair of the Department of Marriage and Family Therapy at Syracuse University and in private practice in Syracuse, New York. Address: Syracuse University, 008 Slocum Hall, Syracuse, NY 13244. E-mails to the author may be sent to Flstone@syr.edu. Letters to the Editor about this article may be sent to Letters@psychnetworker.org.
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by Mary Sykes Wylie
Family therapist Marianne Walters, who died on February 21, 2006, at the age of 76, didn't invent a brilliant new therapeutic paradigm, publish a large and magisterial body of research, or establish her own unique school of clinical practice. Her name never had quite the instant brand recognition associated with some of the founders of the field--Nathan Ackerman, Salvador Minuchin, Murray Bowen, Virginia Satir, and the other immortals. A housewife and mother (who dutifully followed her economist husband around from one academic posting to another for years), she didn't even become a family therapist until she was nearly 40.
Yet, Walters probably had as great an impacto the overall clinical zeitgeist of family therapy, in her own way, as any of the master theory-builders and gurus. Along with her three comrades in arms--Betty Carter, Peggy Papp, and Olga Silverstein--she formed The Women's Project in Family Therapy in 1977, what family therapist Carol Anderson called "the first, biggest, longest-running feminist road show." It was a combination feminist think tank and SWAT team, which, in public workshops all over the country, challenged the underlying sexism in some of the most basic notions of family therapy. Largely at Walters's continued prodding, the four went on to write The Invisible Web, the first book to focus on women's relationships in the family and, more important, on how to bring feminist insights into daily clinical practice.
In these days, when no therapist would admit to not supporting feminist principles, it's almost impossible to resurrect the mix of excitement and outrage Walters engendered, as much because of her truly formidable personality as her unflinching challenge to the male hierarchy. A woman of great personal e[Serbian DJE]lan, fearless temperament, and iron will, she wasn't cowed by authority, to say the least. "She was funny, political, very radical, and wasn't going to soften her position for anyone," remembers psychologist Michele Bograd, who herself has written about feminist issues in family therapy. "She didn't care about her image--she was simply not afraid. Marianne was a warrior-hero to many of us. It was as if she and the Women's Project broke a path through deep, crusted snow that the rest of us could follow."
In all the attention Walters commanded as de facto ringleader of the Women's Project, it was sometimes forgotten that she was also a brilliant clinician, to whom doing therapy seemed to come as naturally as breathing. She had an almost uncanny talent for instantly connecting with clients as if she'd known them forever and somehow startling them out of their funk into a radically new, far more creative and helpful, view of their own dilemmas. Not remotely interested in therapeutic neutrality, she was always fully herself--to be so was part of her working credo. "I'm Jewish," she said, describing one consultation, "so I say 'mazel tov' to this client, instead of 'congratulations'--it's a way of identifying myself and establishing a relationship with the person I'm talking to."
As a teacher, Walters was unforgettable, an ineradicable neon memory, burned into the neural synapses of every student she ever taught. She could be very tough--more than a few students limped out of her supervision sessions feeling scorched by her blunt assessment of their missteps in the consulting room. But she also had a gift for encouraging inexperienced young therapists to think independently of the systems they'd been taught. At a time when family therapists were still deeply in thrall to abstract, formulaic constructions--circularity, complementarity, triangulation, homeostasis, differentiation, enmeshment, not to mention the diagrams and genograms schematically demonstrating these concepts--she challenged students to do therapy less by the book and more from the gut.
For a student or trainee, getting the Walters treatment could be both terrifying and freeing. Larry Levner, director of the Washington, D.C.-based Family Therapy Practice Center, founded by Walters in 1980, describes how disorienting it was for him, as one of Walters's students, to give up his dependence on the neat, predefined sequence of clinical steps that provided a guaranteed road map through any session. "The great thing about the systemic or structural ways of working was that from the minute you entered the therapy room, you knew what you were going to do," Levner says. "When Marianne began challenging family therapy constructs like complementarity, my feeling was, 'I can't do this work if I don't have my formula.' And yet, I remember this period as a defining and empowering time for me as a therapist, when I finally began to understand that therapy wasn't just what you do, but how you think. "
A short woman--only about five feet tall--zaftig of build, with unruly dark hair, a vast smile, and charisma to burn, Walters had undeniable star power and a grand presence that belied her physical stature. "She was divaesque, bigger than life," says Jay Lappin, who was a young faculty member at the Philadelphia Child Guidance Clinic when Walters was there as a family therapist and director of training. "When you were with her, you felt you were with somebody special, and that something important was just about to happen."
The Making of a Radical
Marianne Lichtenstein Walters was a lifelong political activist, who came by her left-wing politics naturally--she was the quintessential "red-diaper baby." Her mother emigrated from Russia to the United States at the turn of the 20th century, speaking only Yiddish, and met Walters's father in New York at a meeting of the Young Person's Socialist League. The couple settled in Washington, where Mr. Lichtenstein got a doctorate in foreign-service studies at Georgetown University.
Finding that Jews weren't welcome at the State of Department, he went into business instead. But while economically comfortable themselves, the family remained steeped in the progressive, prolabor, antiracist political causes of the time. "We were raised in the time of Hitler and grew up understanding what fascism was," says Barbara Bick, Walters's older sister. Her mother was an activist on behalf of civil rights for blacks, and helped to incorporate a cooperative bookstore that included on its board of directors several black professors from Howard University--a radical practice for a white business of the era.
Walters seems to have identified herself as a socialist early on and, as a young woman, even briefly joined the Communist Party. At 17 or 18, she was a delegate to an international youth and student congress held in Prague, where Paul Robeson was one of the speakers. In the heady, earnest spirit of solidarity with the "workers of the world" that informed such occasions, she joined a youth brigade to do volunteer labor on a railroad in either Czechoslovakia or Yugoslavia (accounts differ). But she disliked the work so much that she was grateful when she broke her leg, giving her an unimpeachable excuse to stop--although she did receive some sort of official medal for her efforts.
At the University of California at Berkeley, Walters met and married a left-leaning economist and political activist, Joseph Hart Walters. According to Peggy Papp, Walters liked to tell the fanciful story that her 1950 wedding was a very nice Jewish affair, after which everybody was arrested and taken off to jail for various "un-American" activities. But for all Walters's lifelong commitment to social justice and left-wing sympathies, she was, says her daughter Suzanna, "much too idiosyncratic and independent for any group mentality; too much a free-thinking iconoclast to become mired in orthodoxy."
During a trip to Cuba with other American therapists for an international conference a couple of years ago, she was in a large group of visitors listening to a government functionary talk up the achievements of the Cuban revolution, including free health care and universal literacy. Walters then raised her hand. "Excuse me," she said sweetly. "Have those 79 dissidents and journalists arrested and jailed in 2003 been freed yet, or are they still in prison?" There was a moment of aghast silence before the speaker managed to mumble something to the effect that they hadn't been jailed for their political beliefs but for "other" reasons. The talk resumed. A few minutes later, Walters's hand was in the air again. "I was just wondering," she said, "if you're still rounding up homosexuals and keeping them in special units!"
In 1954, Walters got her M.S.W. degree and took a job as a clinical social worker at the Philadelphia Child Guidance Clinic (PCGC), while it was still under the influence of psychoanalyst Otto Rank. Walters took some satisfaction from the fact that she preceeded by 10 years Salvador Minuchin to the clinic that would become almost synonymous with his name and his pioneering family therapy techniques. She left PCGC in around 1963 to become chief social worker on a Howard University project in Washington, D.C., training community mental health aides. After that, she spent time in Warsaw, Poland (her husband was there on a grant), where her third daughter was born.
In 1968, Walters and her family returned to Philadelphia, where her husband joined the faculty of the University of Pennsylvania and she again joined PCGC. By this time, the organization had been completely reborn as a family therapy center, and was one of the most exciting places to be if you were a social activist, had a rebellious streak, and wanted be in the vanguard of a radical new therapy movement. Walters fit right in.
Not formally trained in family therapy, Walters took to it immediately and quickly became a luminary in her own right. Lappin recalls that when she did supervision, it was if she were "holding court, and people felt lucky to be there." Walters loved the dynamic, politically charged atmosphere of the clinic. "The therapeutic approach seemed so progressive and Sal's politics appealed to me a lot," she recalled. "We'd practically close down the place to go on peace marches. I also liked it that he was always interested in the cultural and social context of people's lives--how poverty affected families. I loved his energy, his intellectual excitement, his commitment and engagement and presence when he was doing therapy." The cozy, teamlike atmosphere of PCGC extended after hours. Walters and Minuchin were neighbors, and their families visited in each other's homes. She, Minuchin and Jay Haley--an early hire of Minuchin's--played poker together for nickel and dime bets.
But, as might be expected in a circle that included a number of leading lights in the family therapy field--generally not shy, self-effacing personalities--there was a certain amount of jostling and maneuvering for position. Often the principal contenders were Minuchin and Walters, who was, by the mid-'70s, executive director of training at PCGC and a star in her own right. One younger staff member recalled how tough the Monday-morning faculty meetings could be, when senior members would stake out positions on different issues, then put junior faculty on the spot by lobbying them to take sides. Typically, Minuchin might say to a junior member of the team something like, "So, what do you think of this idea of Marianne's?" The atmosphere at the clinic was often intensely politicized, and the politics could be intensely personal.
The Making of a Feminist
For Walters, the bloom began to leave the PCGC rose in the mid-1970s, when it began to dawn on her that, however "radical" family therapy seemed, the field was, in her words, "primitive" when it came to women. Gradually, as feminist thinking suffused the cultural atmosphere, she realized how few women were in executive-leadership positions at the clinic, that almost all the major figures in the field were men, and that many women therapists had a hard time confronting men in therapy, much less in their clinics and agencies. Most damning, it seemed to her that the vaunted interventions of family therapy existed in a social vacuum, completely ignoring the real circumstances of women's lives.
According to a well-known story, in 1978, Walters asked her friend Peggy Papp to co-lead a workshop about women and therapy. As far as Walters was concerned, the field had grown so in thrall to its own abstract architectonics of structures and systems that it was losing its anchor in the real, earth-bound world of families, and virtually ignoring the daily reality of women in those families. Papp, in turn, recruited two smart colleagues and former students, Betty Carter and Olga Silverstein. The first workshop, held at PCGC, drew nearly 100 participants, who began to explore what family and couples therapy that included women's experience and consciousness might look like.
One person who hadn't been informed of the workshop was clinic director Minuchin, who discovered the insurrection under his own roof only by accident. "I was always a very intrusive director," he says (he was famous for walking into other clinicians' sessions or offices, unannounced and unapologetic). "I opened the door to the conference room and saw all these women and, at the front of the room, I saw Marianne, Peggy, Olga, and Betty." Taken aback, Minuchin asked what was up. "This is a meeting for women," Walters declared. "But how was it that I didn't know this was going to take place?" Minuchin asked. "You're a man," she said flatly.
"She evicted me," recalls Minuchin, still sounding incredulous nearly 30 years later. "I had the feeling of being pushed out, and I didn't like it. I felt betrayed." Thus began a period of confrontation, Minuchin says, "when I was singled out as the embodiment of male obtuseness and discrimination. The truth is, I really didn't like it at all."
Over the long run, Minuchin says, Walters had an important effect on his own thinking, however. He began to understand that he, too, was the unconscious product of culture--in this case, a patriarchal, hierarchical, macho-infused Argentine family, in which the male was supposed to be top dog. "What I saw as simply the 'natural' way things were, she made me realize, was quite a narrow vision of the world--she opened my eyes."
A few months after the PCGC meeting, at the annual meeting of the American Orthopsychiatric Association conference, Walters, Papp, Silverstein, and Carter decided to hold an impromptu gathering on women's issues and therapy. "We put up a little handwritten sign announcing the meeting, then went to lunch and almost forgot about it--we didn't think anybody would come," Olga Silverstein remembers. When they went to the room scheduled for the event, they found it jammed with nearly 400 people. "We weren't prepared," adds Silverstein, "but we went ahead and did something, and it seemed to go very pretty well." Soon after that, The Women's Project in Family Therapy was born, which kick-started a national movement that ultimately transformed the field.
At some point, the friendship between the four collaborators became as important as the work. After Walters moved to Washington, D.C., and started the Family Therapy Practice Center, one of the first free-standing family-training programs to be run by a woman (Betty Carter's was the first), they continued to meet in Olga Silverstein's New York City apartment. The four would spend the first day updating one another on their personal lives--marriages, divorces, kids. "As we talked, we saw the connection between what we did as parents and wives and friends, and what we did as therapists," Silverstein remarked in a 1997 Networker article about the Women's Project. "We saw that all those roles weren't something that interfered with your professionalism. They made you more of an expert on families."
All four women had their individual identities, backgrounds, ways of working, even physiques. "We were two little women and two tall ones, two Jews and two Wasps--one Catholic and one Mormon," said Silverstein recently. "Our models were all totally different. Peggy and I came from Ackerman, Betty was a Bowenite, and Marianne came from Minuchin's school." By common agreement, Walters was the leader of the pack. "We were four self-motivated, bossy, strong women, but she led us just the same. She kept us together." In fact, when the four began writing their book, it was Walters--often thought of as a confrontationist--who had a gift for soothing jangled nerves, cooling off tempers, and raising spirits when arguments, hurt feelings, misunderstandings, and disappointments threatened progress.
Once the book was published, it became a kind of lodestar to women therapists because it went beyond critiquing sexist assumptions and patterns in family therapy and outlined systematic strategies for making interventions more woman-friendly. The four acquired as much renown as any of the "old masters" of the field. But in certain circles, they became the target of brutal attacks. One major figure circulated a paper that sneeringly used the acronym MAW to describe the group. It pointedly suggested that the four were aggressive, mean-tempered, power-hungry old women who were sacrificing the good name of family therapy to their own selfish yearning for glory.
In retrospect, what adversaries seem to have found most infuriating wasn't that the Women's Project dared to challenge some of family therapy's pet concepts, but the bold, unapologetic, very public and in-your-face way they went about it. And the one who seemed to be the most brazen, most outspoken, least fearful of offending the powers that be was Walters. Not only did she become the de facto lightning rod of the Women's Project, she seemed to take on the job with real gusto.
Putting Families First
While Walters was sometimes regarded by people who didn't know her as an unbending ideologue, she insisted that, for her, feminism wasn't a war against men, but against the monolithic male dominance in the way our culture thinks about and defines human reality. She wanted to include women's experience, women's thoughts, women's perspectives in the way we envision family and society. As committed as she was to the cause, however, she was never doctrinaire. She was too earthy, too rooted in life and aware of its messy ambiguities, too fascinated by people and their individual foibles ever to pigeonhole entire populations into preexisting political categories.
In fact, for somebody with the reputation of a radical, Walters was actually a funny kind of traditionalist, even a moralist, regarding the family--an unreconstructed believer in the necessity of mutually loving and respecting family connections. More than anything, she was a critic of the cult of individualism in American society, which seemed, paradoxically and weirdly in her eyes, to have been adopted by the family therapy establishment. She simply couldn't fathom the vast attraction in family therapy circles to concepts like "differentiation," "separation," and "individuation," nor the zeal of therapists for various strategies aimed at helping "enmeshed" families kick reluctant, postadolescent fledglings out of the nest, nor the cult for "leaving home"--the title of Jay Haley's famous book about getting kids to grow up and get out. "Being a Jewish woman, I just cannot understand separation and boundaries and so on, but I completely understand enmeshment," she said, typically exaggerating for effect. "In our field, you're supposed to grow up in a family and then separate from them, and they're supposed to let you go. But why would you want to let go of your family? Why would you 'let go' of someone you love?" she wondered.
Once, in response to an anxiety-ridden, young, single mother, who was afraid her young son would grow up to be too dependent on her, earning the dreaded label of "mama's boy," Walters dismissed the whole concern with a careless wave of the hand and the immortal remark, "Oedipal, Schmedipal--as long as he loves his mother." In her view, maturity is a process of continually renegotiating the terms of your connection with your family of origin and continually forming new families--with friends, mates, work colleagues, whoever you really care about, who cares about you. "Let a hundred families bloom" might have been her motto.
True, her ideas about "home" and "family" were far more inclusive than the standard-issue, married heterosexual couple with 2.5 children living in a freestanding suburban house. To her, a true family wasn't an institution, but a state of mind and heart--a feeling of being at home with certain chosen others; not a ritualized, privatized legal contract, but the natural unfolding of affiliation between people--whoever they were, whatever their biological connection, whether or not they were formally sanctioned by law and custom. "A home is a place of intimacy and familiarity that holds people who love you and whom you love; a place where you feel taken care of, where you feel comfortable and can talk about things that are important to you," she said
Although she was celebrated as a woman who could dish out challenges to the worldviews of others, her family taught her to readjust her own notions of the correct world order. When, at 16, her youngest daughter, Suzanna, announced to her mother that she was gay, "my mother, typically thinking that she knew it all, without missing a beat, said 'no, you're not!'" recalls Suzanna. Walters herself remembered the occasion with more characteristic hyperbole and self-mocking dramatics. "I said to her, 'That's completely stupid, honey, completely ridiculous. Cut it out! You're always saying something dumb like that. You aren't gay." However, Walters not only came to "accept" her daughter's sexual orientation, but to throw herself into the fight for gay rights with as much joy, enthusiasm, and determination as she had for any of the other causes she'd championed, later thanking her daughter for opening up yet another opportunity for fighting the good fight.
In a profession often known for its avoidance of conflict, Walters will be remembered as an indefatigable fighter who'd go toe-to-toe with anybody on behalf of what she thought was a fundamentally important principle or idea. As Jay Lappin puts it, "That's why I was so shocked when I heard she'd died. I just couldn't imagine Marianne losing a fight to anyone or anything."
Mary Sykes Wylie, Ph.D., is the senior editor of the Psychotherapy Networker . Letters to the Editor about this article may be e-mailed to email@example.com.
by Mary Sykes Wylie
In retrospect, it seems bizarre that hundreds of thousands of veterans, all suffering from similar, dramatic symptoms, could be largely ignored by the Veterans Administration (VA) and psychiatry in general. But before the 1970s, almost no mental health authorities--military or civilian--imagined, much less expected and prepared for, traumatic reactions to war to emerge years after the conflict ended. There was yet no official traumatic stress diagnosis, and the VA assumed that any psychiatric problem occurring more than one year after discharge couldn't be related to military service.
During the Korean War, for the first time, clinicians provided frontline treatment for psychiatric breakdowns, returning the soldiers to battle as soon as possible afterward. Because this approach had worked so well--only 6 percent of Korean War evacuations were for psychiatric reasons, compared with World War II, when 23 percent were--the military was prepared to use the same approach in Vietnam. Only, nobody sought help. In fact, during Vietnam, there were proportionately far fewer reported cases of trauma on the actual battlefield than there'd been in previous wars. The primary reason seems to have been that soldiers had one-year rotations and knew that if they could just hold themselves together for 12 months--often with a little help from their friends, marijuana and heroin--they'd be free.
But after they returned stateside full of relief and happy to be alive, many of them--up to 50 percent according to the National Vietnam Veterans Readjustment Survey of 1988--began breaking down, months or even years later. Why? In spite of its time-limited nature for any individual vet, this war was in many ways even more stressful than others in the nation's history. First, troops were deployed individually, not in cohesive units, which undermined a sense of social support and increased their feelings of personal isolation and alienation. Second, troops were younger and less mature; Vietnam was often referred to as a "teenage war." Third, all wars are nasty, but this one had the special kind of nastiness that goes with a brutal guerilla war. There was an air of murderous futility about what soldiers were expected to do, and little experience of victory or accomplishment. A unit would take a hill one day, suffering massive casualties, only to have to take it again the next day.
And the Vietnamese didn't appreciate being "saved" and "liberated"; it was often impossible to tell friend from foe. As one vet said, "We are the unwilling, working for the unqualified, to do the unnecessary, for the ungrateful."
And the coup de grace: when they got home--deposited in the States maybe 36 hours after seeing a buddy's head shot off--they were unloved, unwanted, unappreciated, and often regarded as a kind of embarrassment. The U.S. had just lost its first war, and by the time it was over, a huge number of people thought the whole thing had just been a terrible mistake and wanted to forget about it. They also wanted to forget about the vets--the ones most visibly associated with the debacle, who kept reminding America that the war wasn't really over. Even veterans organizations were prejudiced against Vietnam vets, sometimes closing their doors to them.
Also, many PTSD symptoms didn't show up as the pitiful twitches and tremblings and motor paralysis that had afflicted the shell-shocked or combat-fatigued soldiers of earlier wars. The symptoms Vietnam vets experienced often appeared far more aggressive and less sympathetic. As public support for the war declined, so did the public perception of veterans, who were often undeservedly portrayed as drunk, drug-addled, brawling, wife-beating, unemployable, whacked-out guys. So it was easy for people to think, as one Vietnam vet wrote, "The Vietnam War was a disgusting and useless mess to which we had sent some of our most disgusting and useless people."
Whatever the VA's official position, however, by the early '70s, there were vast, underground rumblings about something going round the country--some strange, debilitating constellation of symptoms that seemed to be afflicting tens of thousands of returning Vietnam veterans. Trauma specialist Charles Figley, whose 1978 book, Stress Disorders Among Vietnam Veterans, was the first to address the problem, remembers when he became aware of this nameless phenomenon. A Vietnam vet himself and antiwar advocate, he recalls circulating among other vets at the massive 1971 peace rally in Washington, D.C., and listening to men talk about their nightmares, their violent rages and irrational fears, their alcoholism and drug addiction, their difficulty holding onto jobs. It was this experience, he says, that convinced him to go back to school and study psychology to find out what was happening to so many of his fellow soldiers.
Beginning in the mid-'70s, vets all over the country became very active, forming hundreds of rap groups to talk about their war experiences and coalescing into large, politically powerful, organizations to struggle for financial, social, and medical recognition of their problems. Many of the psychiatrists and psychologists who treated these vets and led rap groups were Vietnam veterans themselves, and they became forceful allies in the drive to get better care from the VA. Finally, in 1979, Congress officially mandated the VA to provide a network of counseling centers for Vietnam vets, to treat their "readjustment problems," including the as-yet-named PTSD. Even so, VA hospitals didn't begin to provide treatment aimed at trauma until the early '80s, after PTSD was included in the DSM-III (the third edition of theÂ Diagnostic and Statistical Manual of Mental Disorders ).
By the late 1970s, it had become obvious to many therapists that the old diagnostic system had fatal flaws. DSM-II seemed to have been written for a world in which serious trauma virtually never occurred. If somebody did perchance experience what DSM-II called "overwhelming environmental stress" (details never specified), it was assumed that, once the stress had been eliminated, recovery would occur in short order without any special help. If recovery didn't speedily happen, "another mental disorder is indicated"--suggesting that the failure to get better lay in the patient's own inherent psychological weakness or vulnerability, and had nothing to do with the trauma.
While the veterans were struggling for recognition on one front, another campaign was being waged--which included some of the same people--on another, to get traumatic stress back into the DSM. In 1974, psychiatrist Chaim Shatan, who was in the vanguard of the fight for better mental health care for veterans, heard about a New Jersey public defender representing a Vietnam vet accused of committing violence against property--an action for which the vet claimed amnesia. The public defender tried to get his client declared not guilty based on traumatic war neurosis, but the judge rejected the defense, saying there was no such diagnosis.
Shatan told the public defender to contact Robert Spitzer, head of the task force that he knew was then beginning preparations for the new DSM-III, assuming that there'd be such a diagnosis in the upcoming manual. But Shatan and other veteran advocates were shocked to hear that Spitzer had no plans to include any diagnosis for war neurosis in the new edition.
So Shatan contacted other psychiatrists who'd studied the psychological impact of war and genocide--including Robert Lifton, author of a book about Hiroshima victims and later a book about Vietnam, as well as psychiatrists William Niederland and Henry Krystal, researchers studying Holocaust and concentration-camp survivors--to mobilize support to their cause. Eventually, they helped form the Vietnam Veterans Working Group, comprising vets, psychiatrists, mental health organizations, academics, antiwar activists, church groups, and the like to lobby the American Psychiatric Association on behalf of a PTSD diagnosis.
Meanwhile, Charles Figley, who'd founded the Consortium on Veteran Studies at Purdue University and had led several symposia on vets at psychological conferences, published Stress Disorders Among Vietnam Veterans, which also became ammunition in the effort. Eventually, Spitzer agreed to form a committee to study PTSD, and, in 1980, PTSD was finally included in DSM-III.
For the first time, an official DSM diagnosis assumed a psychological disorder was caused not by inner dynamics or neurotic predisposition, but by outer events that happened to the person. In fact, without the trauma, there's no diagnosis. And the trauma itself had to be something truly big and bad. DSM-III distinguished--as DSM-II hadn't--between life's ordinary vicissitudes that might generate a psychological "adjustment reaction" and traumatic events that would most likely overwhelm someone, like natural disasters, rape or assault, bombing, torture, death camps, military combat, plane crashes, and so on. The events had to be "outside the range of normal human experience," represent a threat to life and limb, and be experienced by the victim with intense feelings of fear, helplessness, and horror.
The diagnosis was as much a political victory as a shift in the terrain of mental health. For the first time, political advocacy and social consciousness overtly contributed to the creation of an official diagnostic category for a psychiatric illness, taking into specific account the recent man-made horrors of world history--war, torture, genocide. This was also the same DSM that, in another highly politicized process, removed homosexuality from the list of mental disorders. So it wasn't surprising that some critics maintained--and still contend--that both the inclusion of PTSD and the exclusion of homosexuality owed more to politics than science.
--Mary Sykes Wylie
by Jay Efran
There is a basic inequality built into the therapy contract--we ask clients to disclose their vulnerabilities, while we hide behind a facade of unflappability, presumably floating above ordinary human foibles, untouched by the jolts and discouragements of life. We're not supposed to discuss our personal problems, or even acknowledge having any. While preaching congruence, who among us has never pretended fondness for a client we actually disliked, didn't understand and didn't trust? But on at least two ticklish occasions, with a minimum of strategic deliberation, I opted to step out from behind my own well-cultivated facade of inscrutability to tell clients the unvarnished truth--with surprising results.
The first time came at the end of a particularly long and trying day that had started promisingly enough in the office of a colleague with whom I had spent almost two years working on a book. But that morning, he informed me that after rereading the first three chapters--the part I had considered finished--he had come to the conclusion that the material had to be completely reworked. What was worse, changes in these early sections would affect everything else in our draft. He was talking about another year's work--if it could be done at all. To make matters worse, I could see at once that he was absolutely correct. I was so stunned that once he had finished delivering his verdict, I got up without a word and stalked out of his office. All I could think of doing was tossing the manuscript in the nearest trash can and calling it quits.
Walking home, I found myself spiraling into the kind of depression I hadn't experienced since I broke up with my most alluring high school girlfriend. I avoided my wife, went up to my home office, skipped lunch and didn't talk to anyone for hours.
In the middle of the afternoon, I glanced at the calendar and was dismayed to see that a client was due at any moment. I considered asking my wife to meet her at the door and explain that I had suddenly become violently ill--maybe some sort of food poisoning--and that I would be in touch to reschedule.
Then, for some reason, I felt a sudden impulse to go in a different direction--to simply tell the client the truth about what had happened that day. When Jenny, a perennially frazzled lab technician, came in and sat down, I immediately announced, "Today, I might be the one more in need of help." After describing what had transpired, I admitted that I had considered canceling but thought better of it. However, although I wanted to proceed with the session, I indicated that I was not planning to charge for it. After all, given my mood, I wasn't sure how much of my attention I would be able to muster for the task at hand. "In fact," I said only slightly tongue-in-cheek, "if you expect to use any 'air time,' you had better come up with some damn good problems to talk about."
In retrospect, I should have charged double. We soon became engaged in an energized give-and-take about how setbacks can convulse our lives and how difficult it can be to regain composure, even after the immediate crisis has passed. We both laughed about the ridiculously melodramatic pronouncements we usually uttered in the midst of such emotional distresses and the complexities of saving face later on. As we talked, I felt my own mood lift, but I also saw something emerge in Jenny that I hadn't seen before. She was proud of being able to gracefully yield center stage and empathize with someone else's troubles for a change. She liked the trust implied by my willingness to share my experience with her, and she profited from knowing that none of us is impervious to life's setbacks.
That evening, feeling much better, I called my coauthor, apologized for having "lost it" at our meeting and outlined a plan for digging into the repair work needed on our ailing manuscript. Restored by my time with Jenny and the freedom to acknowledge what had happened to me earlier that day, never again would I underestimate the value of just giving an upset client a safe place to vent.
Telling It Like It Is
A few years later, I had a chance to stretch myself even more with a client. Tim was one of the few clients to whom I have taken an almost immediate dislike. Referred by his wife, he carped nonstop about his thankless duties as a foreman in a small carpentry shop and his hassles with his in-laws, who lived just around the corner. His second session was more of the same, and I felt a growing irritation with his self-absorbed whining.
Midway through our third session, I found myself wondering how much longer this could go on. As Tim droned on with his litany of complaints, I became increasingly annoyed and confused. I knew we had gotten off to a shaky start, but I wasn't sure why. I sensed that it was time for decisive action, although I didn't know what. Then, I found myself uttering the following two statements: "Tim, I have two things to tell you," I said. "First, I don't like you. Second, I don't believe anything you have been saying." My words sounded harsher than I had intended, and in the silence that followed, I toyed with the idea of softening the impact with more nuanced words. But before I could recant, he said, "Frankly, I don't like you either. And besides, I think therapy is a complete crock."
"Now, those are the first things you said that I believe," I responded, and I asked him why, in that case, he had come in at all. He explained that his wife thought he needed help for his "temper" problem, and he had promised to give it a try. I told him that his wife's positive experience with therapy was not a sufficient reason for us to continue working together. He seemed relieved to be done with this charade and, frankly, so was I.
As he walked out the door, I was sure that was the end of it. Therefore, I was astonished when he called four months later to ask if he could stop by. He was the last person I had expected to hear from.
Talking to him this time around was like meeting someone new. He was warm and friendly, with none of the wary self-absorption that had once made me so impatient. He freely admitted that he needed help and confessed that--if I would still see him--I was his first choice for the job. We quickly formed a strong therapeutic partnership and worked together efficiently for the remainder of that summer. I grew to like and respect him, and I looked forward to each of our sessions.
Although he made a good living, Tim was a school dropout, while his wife was a college graduate. He told me he felt that his wife's family had never really accepted him, and he was always uncomfortable in their presence. He also felt out of place with his wife's friends, whom he considered stuck-up.
Tim could be quick tempered and judgmental, but I learned that he was also good hearted with a kind of boyish, down-to-earth charm. Through our work together, he lightened up about the reactions of others and less often felt a need to prove himself.
Later, he told me that the only reason he had returned after those initial meetings and was willing to let down his guard was that I had spoken so candidly. "I realized that I could always count on you to tell me the truth," he said. "I hate bullshit," he added, "especially my own!"
These days, I rarely hesitate to share my frank reactions with clients, most of whom, I have come to realize, are far hardier than we were taught to believe. If the setting is right, even brutal honesty can advance the therapeutic cause. In fact, over the years, I have discovered a very handy therapeutic mantra to consider whenever the work bogs down, "When you find yourself stuck, try the truth."
Jay Efran, Ph.D., is professor of psychology and director of the Psychological Services Center at Temple University. He is a coauthor of Language, Structure, and Change: Frameworks of Meaning in Psychotherapy. Address: Department of Psychology, Temple University, 1701 North 13th Street, Weiss Hall 413, Philadelphia, PA 19122-6085. E-mails to the author may be sent to J.Efran@worldnet.att.net. Letters to the Editor about this article may be sent to Letters@psychnetworker.org.
by Mary Sykes Wylie
Bessel van der Kolk likes to introduce his workshops on Post-Traumatic Stress Disorder (PTSD) with medical film clips from World War I showing veterans diagnosed with what was then called "shell shock." In these dramatic and riveting clips, one soldier sits hunched over on his hospital cot, staring blankly ahead, responding to nothing and nobody until the single word "bomb" is said, whereupon he dives for cover underneath the small bed. Another man lies almost naked on the bare floor, his back rigidly arched, his arms and hands clawing the air as he tries, spasmodically and without success, to clamber onto his side and stand up. Yet another, who once bayoneted an enemy in the face, now opens his mouth wide into a gaping yaw and then closes it, and opens it and closes it, over and over and over again.
The images are disturbing, heartbreaking, and all the stranger because these particular men, technically speaking, are physically unharmed. Their physical symptoms--paralysis, violent trembling, spasmodic movements, repetitive facial grimaces, zombielike demeanor--look exotic to our eyes because PTSD generally doesn't show up like this anymore in most clinicians' offices. Time and Western cultural evolution have changed the way traumatized people express their distress in a therapist's office. Now, trauma patients may look fine on the surface, but complain of nightmares, flashbacks, feelings of numbness, generalized fearfulness, dissociative symptoms, and other problems that aren't as visible to the world at large. But to van der Kolk, these old images still represent what he calls the "pure form" of PTSD. The appearance in these World War I film clips that the veterans are possessed, mind and body, by invisible demons still captures the fundamental truth about PTSD--that it can reduce its victims to mute, almost animal-like, creatures, utterly isolated in their fear and horror from the human community.
Van der Kolk first became aware of the world of trauma in 1978, when he decided to go work for the Veterans Administration (VA), not to study PTSD (it hadn't been recognized yet as a formal diagnosis), but to get the government benefits to pay for his own psychoanalysis. While there, he discovered the reality of PTSD--and the beginnings of a stunning, nationwide phenomenon. "At that time, tens of thousands of men who'd served in Vietnam suddenly seemed to come out of the woodwork, suffering from flashbacks, beating their wives, drinking and drugging to suppress their feelings, closing down emotionally," recalls van der Kolk. "It was a phenomenon that spawned a whole generation of researchers and clinicians fascinated by what had happened to these guys."
Van der Kolk himself soon became intrigued by the mysterious mental and emotional paralysis that seemed to afflict these traumatized veterans. Why, he wondered, did many of his patients seem so stuck emotionally in their horror that they relived it over and over in flashbacks and nightmares? What kept these men circling round and round on an endless treadmill of memory, unable to step off and resume life? In spite of their obvious suffering, why did they seem so obsessively attached to their traumatic experiences?
In the 25 years since then, the trauma field has gone from obscurity, if not disreputability, to become one of the most clinically innovative and scientifically supported specialties in mental health. Trauma researchers have led the pack in setting off an explosion of knowledge about psychobiology and the interaction of body and mind. And van der Kolk, as much as anyone else in the field, has defined the current framework for understanding trauma.
He's the author of more than a hundred peer-reviewed scientific papers on subjects such as self-mutilation, dissociation, the therapeutic efficacy of Eye Movement Desensitization and Reprocessing (EMDR), the developmental impact of trauma, and the nature of traumatic memories. He's also been a featured contributor in most of the standard textbooks in the trauma field. In addition to teaching at Boston University, Tufts, and Harvard, he directs the Trauma Center in Boston, possibly the largest trauma specialty center in the country, with 40 clinicians working with clients who range from infants to geriatrics, from incest survivors to international torture victims. Inhabiting both the world of the clinician and the researcher, he also runs a major research laboratory at the Trauma Center, staffed by 15 researchers who investigate everything from neuroimaging of treatment effects on the brain to the effects of theater groups on violent, traumatized teenagers.
Glowing testimonials about his contributions aren't hard to come by from the field's leading lights. "Very early on, more than anybody else, he introduced neurobiology to the trauma field, and helped us see the interaction between mind and body in trauma," says Charles Figley, professor at the School of Social Work at Florida State University and Vietnam vet, whose early work on war trauma is often credited with prompting the inclusion of PTSD as a diagnosis in the DSM (see sidebar, page X). "He's one of the most generative and creative minds in the trauma field, and his influence has been pervasive," says psychiatrist Judith Herman, renowned trauma expert at Harvard Medical School.
At the same time, van der Kolk is also one of the trauma field's most controversial figures. Often prickly, rarely shy about offering his own opinions, and unafraid of a good fight, he's scandalized a number of cognitive-behavioral therapists and academic researchers by openly embracing EMDR, demonstrating an interest in such truly outre techniques as Thought Field Therapy, enthusiastically taking up nonstandard somatic therapies, and even sending his patients off to participate in theater groups and martial arts training.Van der Kolk's bold criticism of the orthodoxies of psychotherapy and public advocacy of somatic approaches have, in particular, outraged many. "Advocating unproven body psychotherapies is professionally irresponsible," says Edna Foa, professor of psychology in the psychiatry department at the University of Pennsylvania. "He's marginalized himself as a scientific thinker--he's no longer in the mainstream," adds Richard Bryant, noted trauma researcher and psychology professor at the University of New South Wales in Australia. "Until he provides data in support of his new [somatic] approach, the field isn't obligated to pay any attention to what he's doing," sniffs psychologist Richard McNally, author of the widely cited Remembering Trauma, a critique of recovered-memory theory.
The intensity of response van der Kolk kicks up is an indication of the crusader's fervor underlying his work and his determination to make the field viscerally understand that trauma isn't simply a neutral mental health issue, but a profoundly moral concern. Spicing his talks with earthy, Dutch-accented American slang, van der Kolk regularly reminds his audience in a tone of subdued indignation that trauma forces the reality of human evil into our consciousness, often the evil of presumably good and upright people--our neighbors, our leaders, our families, and ourselves. It's not a perspective people always welcome because, as he writes in his book Traumatic Stress, most of us like to believe "that the world is essentially just, that 'good' people are in charge of their lives, and that bad things only happen to 'bad' people. . . . Victims are the members of society whose problems represent the memory of suffering, rage and pain in a world that longs to forget."
A Diagnosis Non Grata
While trauma is always clinically described as a horrifically abnormal event, for any casual student of the human condition, it's actually a perfectly normal feature of history, one that has emotionally scarred billions of men, women, and children since before the beginning of recorded time. And yet, while philosophers, writers, and ordinary people have always known that terrible events can cause a lifetime of psychological pain, until the latter part of the 20th century, mental health professionals were oddly blind to this fact of life. "Psychiatry itself has periodically suffered from marked amnesias in which well-established knowledge has been abruptly forgotten," writes van der Kolk in Traumatic Stress, "and the psychological impact of overwhelming experiences has been ascribed to constitutional or intrapsychic factors alone." In other words, a failure to "get over" a trauma was often ascribed to personal weakness or an unconscious desire not to recover.
Even the official nosology of the psychiatric profession reflected this peculiar obtuseness. The 1952 edition of the Diagnostic and Statistical Manual of Mental Disorders ( DSM-I ) had included combat-related stress under the diagnosis of "gross stress reaction," but this was dropped from the DSM-II in 1968--the same year that troop strength reached its peak in Vietnam. All that was left of trauma in DSM-II was the pallid diagnosis "adjustment reaction to adult life," under the general heading of "transient situational disturbance." Adjustment reaction was a grab-bag diagnosis, including "fear associated with military combat and manifested by trembling, running and hiding" and "unwanted pregnancy." It wasn't until 1980, after years of lobbying and wrangling, that PTSD was included in DSM-III (see sidebar page 37).
So when van der Kolk first went to the VA in 1978, not only was there no official traumatic stress diagnosis, but the VA assumed that any psychiatric problems occurring more than one year after discharge couldn't be related to military service. Besides denying veterans any compensation for delayed traumatic reactions--probably the overriding consideration in the VA's longstanding lack of interest in the enduring impact of "combat stress"--this rule effectively scotched any research or clinical treatment directly focused on trauma. "When I went to work for the Boston VA," remembers van der Kolk, "there wasn't a single book in the library on war neurosis."
Unable to do research on war trauma because the VA wouldn't fund studies on a diagnosis that didn't exist, van der Kolk and his colleagues did the first study ever on the real nightmares the vets had and, in another first, used the Rorschach inkblot test to reveal the twin pattern of hyperarousal and dissociation that traumatized vets showed. For van der Kolk, this research pointed to the paradoxical conundrum at the heart of trauma. "This is still the issue with traumatized people--they see and feel only their trauma, or they see and feel nothing at all; they're fixated on their traumas or they're somehow psychically absent." In either case, traumatic memories from the past have utterly usurped the present.
By the late-1980s, van der Kolk had had extensive experience working with vets and was becoming a well-known figure among PTSD researchers. He'd been responsible for several important studies, including, besides the Rorschach and nightmare papers, research into psychopharmacology and trauma, and had published the book Post-Traumatic Stress Disorder: Psychological and Biological Sequelae, the first book published specifically about PTSD. But in spite of his impressive reÂ´sumeÂ´, he felt deeply discouraged. He'd learned a lot, but he didn't think he was fundamentally helping his patients. Even after months or years of work, his patients still suffered from flashbacks, nightmares, depression, aggressive rage, anxiety. They still either couldn't talk about their trauma at all or when he pushed them to talk about it--as he and many therapists often did, and still do--they began hyperventilating, shaking, yelling, crying, became physically agitated, or just collapsed in a state of helpless fear and dread. "I'd become a reputable PTSD researcher and clinician, but I felt I'd utterly failed my patients," van der Kolk remembers. "I guess they thought I was a good guy, they felt understood by me, but that didn't necessarily help them to get back into their lives."
And what was the treatment that he felt was not really helping his patients to move on? It was standard talk therapy 101--helping them explore their thoughts and feelings--supplemented with group therapy and medications. During individual sessions with clients, he often focused intensely on patients' past traumas, in the interest of getting them to process and integrate their memories. "I very quickly went to people's trauma, and many of my patients actually got worse rather than better," he says. "There was an increase in suicide attempts. Some of my colleagues even told me that they didn't trust me as a therapist."
The Neurobiology of Trauma
The fundamental conundrum of how trauma affects the mind and body that still plays out in treating trauma survivors was already crystallizing in van der Kolk's mind 20 years ago. "When people get close to reexperiencing their trauma, they get so upset that they can no longer speak," he says. "It seemed to me then that we needed to find some way to access their trauma, but help them stay physiologically quiet enough to tolerate it, so they didn't freak out or shut down in treatment. It was pretty obvious that as long as people just sat and moved their tongues around, there wasn't enough real change."
Back in the early 1980s, believing that future progress lay in a better understanding of the biology--particularly the neurobiology--of trauma, van der Kolk had applied for a VA research grant on the subject. Even though PTSD was now "official," his proposal was turned down flat. The opening sentence of the rejection letter still vividly resonates in his mind. "It's never been shown that PTSD is relevant to the mission of the Veterans Administration." Since then, the VA has grown up and become a leading supporter and funder of trauma research, but in the early '80s, it was clearly a diagnosis non grata to the establishment. Both dumbfounded and enraged by the VA's response, van der Kolk says he never read past that first sentence, and decided right then to seek greener pastures and put in his notice.
He moved back to the Massachusetts Mental Health Center, a state hospital and psychiatric teaching institution associated with Harvard Medical School, where he'd received his psychiatric training and, before that, had spent a year as a mental health worker on a research ward for unmedicated schizophrenic patients. Here he discovered how easy it is for the best-intentioned therapist to inadvertently make traumatized patients worse. He was struck how some female patients fell apart during personal contacts with him and other male staff, becoming agitated and assaultive. Why would they so suddenly switch from being pleasant and sensible, to losing their minds when a man would pay attention to them? he wondered. Looking into the histories of the women, most of whom had been diagnosed as borderlines or schizophrenics, he found that they'd all been severely and chronically sexually abused as children and adults.
Van der Kolk began to realize that, for these women, being in a room alone with a man who directed questions at them emotionally hurled them back into their traumas. He noted that their entire bodies responded as if they were being molested again--heart pounding, muscles tensing--they seemed, literally, to take leave of their senses--unable to distinguish now from then. "It seemed that their traumatic memories, like those of Vietnam veterans, prevented them from being able to modulate their autonomic arousal," he observes. "Their physiological housekeeping systems had been messed up by trauma."
It now seemed to him that chronic trauma explained a great deal about how borderline patients acquired their deep impairments, and why they were so hard for therapists to treat. "Borderlines have a terrible reputation because they often are simply impossible," says van der Kolk. "They cling to you and then hate you, and, either way, they won't leave you alone. But if you look at their behavior through their traumatic background, it makes perfect sense. If you've been raped and abused for years as a child and adult, your entire organism and personality has been organized around your trauma. If they have PTSD, the way they act is understandable--they're not just people trying to make your life miserable, but people trying to survive."
Van der Kolk's experience with borderlines reinforced his belief that talk therapy by itself, even in the context of a warm, supportive therapeutic encounter, wasn't enough to reverse the profound physical and emotional changes wrought in his patients by pervasive trauma. But he credits Hurricane Hugo with showing him see just how physical helplessness contributes to the development of serious post-traumatic symptoms, and making him wonder if physical movement might not contribute to healing.
In 1989, directly after Hurricane Hugo had ravaged Puerto Rico, van der Kolk accompanied FEMA officials to lend his expertise to dealing with the traumatic aftermath of the devastating storm. "I arrived in the middle of this devastation, and what I saw were lots and lots of people working with each other, actively putting their lives back together--carrying lumber, rebuilding houses and shops, cleaning up, repairing things."
But the FEMA officials immediately told everybody to cease and desist until assorted bureaucracies could formally assess the damage, establish reimbursement formulas, and organize financial aid and loans. Everything came to a halt. "People were suddenly forced to sit still in the middle of their disaster and do nothing," van der Kolk remembers. "Very quickly, an enormous amount of violence broke out--rioting, looting, assault. All this energy mobilized by the disaster, which had gone into a flurry of rebuilding and recovery activity, now was turned on everybody else. It was one of the first times I saw very vividly how important it is for people to overcome their sense of helplessness after a trauma by actively doing something. Preventing people from moving when something terrible happens, that's one of the things that makes trauma a trauma."
Pondering this striking lesson, van der Kolk wondered if perhaps the most damaging aspect of trauma wasn't necessarily the awfulness of it, but the feeling of powerlessness in the face of it, the experience of being unable to escape or fight or have any impact on what was happening. "The brain is an action organ," he says, "and as it matures, it's increasingly characterized by the formation of patterns and schemas geared to promoting action. People are physically organized to respond to things that happen to them with actions that change the situation." But when people are traumatized, and can't do anything to stop it or reverse it or correct it, "they freeze, explode, or engage in irrelevant actions," he adds. Then, to tame their disorganized, chaotic physiological systems, they start drinking, taking drugs, and engaging in violence--like the looting and assault that took place after Hurricane Hugo. If they can't reestablish their physical efficacy as a biological organism and recreate a sense of safety, they often develop PTSD.
The Monopoly of Talk
Van der Kolk was now sure that, just as the experience of physical helplessness was at the core of trauma, there was something about frustrated action to repair the situation that played a role in developing long-term PTSD. And he began to wonder if helping traumatized people engage in meaningful, physical action would allow them to recover from PTSD. His growing sense that the body, as much as the mind, might hold the key to recovering from trauma ran up against the sacrosanct tradition of the talking cure as the alpha and omega of all psychotherapy. It was about this virtual monopoly of mainstream therapy by institutionalized talk that van der Kolk was becoming increasingly skeptical.
Talk is relevant--even vitally important--he says, for traumatized patients who don't yet really know what's happened to them, who were too young to understand what was happening, who weren't listened to or believed, or who still can't make sense of what happened. His own therapy is still "very talky," he adds. But, van der Kolk continues, "fundamentally, words can't integrate the disorganized sensations and action patterns that form the core imprint of the trauma." Treatment needs to integrate the sensations and actions that have become stuck, so that people can regain a sense of familiarity and efficacy in their "organism."
Van der Kolk is also very tough on the old shibboleth of psychotherapy-as-restorative-relationship. Too often, he insists, trauma patients and therapists both move into a quasi-relationship because, that way, they can both evade the real pain of focusing on and dealing with the physical trauma imprints. "Clients may look for 'relationship' in therapy because they can't stand what they feel in their own bodies--as long as the therapist is with them, they can distract themselves from their inner experience. The 'felt sense' has become a minefield, and clinging to others is one way of avoiding the intolerable sensations within," says van der Kolk. But what patients really need, he believes, is the "therapist's attuned attention to the moods, physical sensations, and physical impulses within. The therapist must be the patient's servant, helping him or her explore, befriend, and trust their inner felt experience." Relationship therapy can seem like a kind of ersatz friendship, but "it doesn't make you better friends with yourself."
To underscore the shocking possibility that neither talk nor relationship may be necessary in trauma treatment, van der Kolk likes to tell the story of his training in Eye Movement Desensitization and Reprocessing (EMDR), an approach held in very low esteem by many of his research colleagues. Although he initially considered EMDR a fad, like est or transcendental meditation, he went for the training after seeing the dramatic effects it had on some of his own trauma patients. "They came back and told me how supportive our therapy relationship had been, but that EMDR had done more for them in a few sessions than therapy with me had done in four years," he recalls. Van der Kolk decided to go see for himself what this weird new thing was all about, and took the training.
He didn't like the training at all: "It felt too packaged, too much like a Billy Graham revival-type thing." He was, however, amazed at what happened to him when he subjected himself to EMDR as part of the training. The Trauma Clinic he'd established at Massachusetts General Hospital in 1991 had recently been closed--ostensibly for budgetary reasons, but most likely, he suspected, because of his high-profile advocacy of clergy-abuse victims, while his then department chair, a Jesuit priest, was serving as the principal advisor to Cardinal Law, who's since resigned after being accused of covering up incidents of pedophilia among more than one hundred priests in the Archdiocese of Boston. The sudden closing of the Trauma Clinic was the focus for his EMDR session. "During the session, I was fascinated by all the different images from my early childhood that made their way very rapidly through my consciousness, and which seemed somehow related to the loss of my clinic. It was like the kind of hynopompic experience you have when you first begin to wake in the morning, with ideas coming and going and being forgotten before you really wake up." Afterward, he felt as if "something had been processed and left behind," and his distress about the clinic's closing had significantly lessened.
His own EMDR practice student during the training was another clinician, who refused to tell van der Kolk anything about what he wanted to work on, except that it was "some very tough stuff between me and my dad when I was little." Overtly hostile and uncommunicative throughout the session, the clinician kept saying that he didn't really want to share what he was upset about. As a result, van der Kolk was totally in the dark about what was going on inside the person he was trying to "help" with the EMDR.
At the end of the session, the man looked relieved of much of his distress.
"How was that?" van der Kolk asked.
"I'd never refer a patient to you," the man barked at him.
Van der Kolk replied, "Oh, why is that?"
The man replied, "I really hated the way you dropped your fingers at the end of each movement!"
"But what about your original problem?" van der Kolk asked.
"Oh, I feel I completely resolved the issue with my dad."
This episode engaged van der Kolk's curiosity about the role of the therapeutic relationship. "This guy didn't trust me. We didn't have a warm relationship. I never knew anything about what was bothering him. Yet he seemed to have processed whatever it was he needed to take care of. It drove home to me the possibility that maybe people can do excellent therapeutic work, even if they don't like and trust you (as happens, of course, in many victims of interpersonal trauma), as long as the therapist knows how to help them "digest" the imprint of the trauma."
Bottom Up, Not Top Down
In 1994, van der Kolk published a paper called "The Body Keeps the Score," in which he reviewed the existing research about the neurobiological underpinnings of traumatic reactions. The paper described how trauma disrupts the stress-hormone system, plays havoc with the entire nervous system, and keeps people from processing and integrating trauma memories into conscious mental frameworks. Because of these complex physiological processes, van der Kolk explained in the paper, traumatic memories, in effect, stay "stuck" in the brain's nether regions--the nonverbal, nonconscious, subcortical regions (amygdala, thalamus, hippocampus, hypothalamus, and brain stem), where they're not accessible to the frontal lobes--the understanding, thinking, reasoning parts of the brain. In short, he demonstrated with four-part scientific harmony that it was our bodies, not our much-vaunted minds, that control how we respond to trauma, what we do and don't consciously remember, and whether we recover from it or live in thrall to it. "We're much less controlled by our conscious, cognitive appraisal than our psychological theories give us credit for being," van der Kolk remarks dryly.
For a densely written article on psychobiology, "The Body Keeps the Score" had a far-reaching impact that brought van der Kolk into much wider circles of therapists than his previous books had done. For this, he credits the article's catchy title. "If you want to write something that gets people's interest, give it a great title. People wanted to know what the hell that article was all about." The paper attracted the interest of Scott Rauch, director of the neuroimaging lab at Massachusetts General, who asked van der Kolk if he'd like to take a look inside the brains of some of his trauma patients--something that would have been unthinkable before the '90s. The neuroimaging team scanned the brains of eight trauma-patient volunteers. The first scan was while they remembered neutral events in their lives, and the second scan was when they were exposed to scripted versions of their traumatic memories.
During the scanning, the images actually showed dissociation happen in the brains of these PTSD patients. When they remembered a traumatic event, the left frontal cortex shut down--particularly Broca's area, the center of speech. But areas of the right hemisphere associated with emotional states and autonomic arousal lit up, particularly the area around the amygdala, which might be called the "smoke detector" center of the brain. According to van der Kolk, what this suggested is that "when people relive their traumatic experiences, the frontal lobes become impaired and, as result, they have trouble thinking and speaking. They no longer are capable of communicating to either themselves or to others precisely what's going on."
Other neuroimaging studies Van der Kolk has collaborated on since also showed that the executive functions of the brain become impaired when traumatized people try to access their trauma. "The imprint of trauma doesn't "sit" in the verbal, understanding, part of the brain, but in much deeper regions--amygdala, hippocampus, hypothalamus, brain stem--which are only marginally affected by thinking and cognition. These studies showed that people process their trauma from the bottom up--body to mind--not top down." But if trauma is situated in these subcortical areas, "then to do effective therapy, we need to do things that change the way people regulate these core functions, which probably can't be done by words and language alone."
So what could trauma therapists do to help people "regulate their core functions"? Perhaps because of its title, van der Kolk's article caught the immediate and excited attention of many body psychotherapists, who'd worked with trauma patients for years, but had generally been dismissed--if noticed at all--by the psychiatric establishment as New Age flakes. To them, "The Body Keeps the Score" was something like an unexpected benediction from on high. "For the first time, a traditional, mainstream psychiatrist and neurobiology researcher was legitimizing the importance of understanding the effects of psychological disturbance on the body," says Babette Rothschild, a private practitioner in Los Angeles and author of The Body Remembers: The Psychophysiology of Trauma and Trauma Treatment. "It was very exciting to have him confirm what many practitioners had believed for a long time--that there's something called somatic memory."
If the body people were entranced with van der Kolk, the feeling was mutual. As he looked out into the audience before delivering an address to them at this time, he remembers thinking, "How well put together these people all look compared to a typical audience of psychotherapists." But while they appreciated his presence and what it stood for--his recognition that understanding the body was key to understanding the mind--he seemed to think they had more to teach him than he had to teach them. "I gave my talk, and a bunch of the people there shook their heads and said, 'this poor fellow--he knows a little bit about the body, but he really doesn't understand it.' Several took pity on me and offered to teach me what I needed to learn."
The body therapists made him see how much of the work of healing from trauma is, he says, "really about rearranging your relationship to your physical self. If you really want to help a traumatized person, you have to work with core physiological states and, then, the mind will start changing." He adds, "if clinicians can help people not become so aroused that they shut down physiologically, they'll be able to process the trauma themselves. Therapists must help people regulate their affective states. That's what we do. We do it so a person can find the strength to face her own inner horrors and begin to move and regain a life for herself."
One body therapist whose work especially impressed van der Kolk was Peter Levine, the developer of an approach to trauma treatment called Somatic Experiencing. Trauma, argues Levine, is "'locked' in the body, and it's in the body that it must be accessed and healed." PTSD, he argues, is "fundamentally a highly activated, incomplete, biological response to threat, frozen in time." All animals, including humans, are physically programmed by evolution to flee, fight, or freeze in the face of grave threats to life and limb. But in humans, when these natural responses to danger are thwarted and people are helpless to prevent their own rape, or beating, or car accident, the unfinished defensive actions become blocked as undischarged energy in their nervous systems. They remain physiologically frozen in an "unfinished" state of high biological readiness to react to the traumatic event, even long after the event has passed. The undischarged energy of the blocked response to the trauma eventually metastasizes into the full-fledged panoply of PTSD symptoms. Levine believes that psychological trauma is very much about action interruptus, which the traumatized human organism still needs to complete.
Levine believes that trauma victims, having been totally helpless and unable to move--physically and psychologically--must regain in therapy that lost capacity to move, to fight back, to live fully in their bodies as much as in their minds. Instead of curling up into scared little balls when threatened, these patients need to learn in the very cells of their bodies that they can stand up and kick butt.
Just how to help numbed and terrified trauma clients acquire a little more of the Rambo spirit is demonstrated in another video van der Kolk likes to show at workshops. It features a body therapist named Pat Ogden, originator of a treatment method called Sensorimotor Psychotherapy. In it, the client--a young woman sexually abused as a child--says very faintly early in the session, "I'm not feeling my body" and "I'm just about gone," indicating that the memory of the abuse causes her to shut herself down--go numb, blank, and frozen-in order not to feeling anything. "At this point," comments van der Kolk, "she's basically not there. The moment you're not feeling your body, you're gone, because the body really is the engine of aliveness, of thought. As long as people don't feel their bodies, we're wasting our time and theirs trying to do talking psychotherapy." With great emphasis, he adds, "Becoming comfortable in their bodies is, for our patients, the number-one, paramount issue, and if we can't help them do that, then we can't help them at all."
In the video, Ogden tracks the woman's growing physical discomfort in the early stages of the session, helping her to focus on her feelings, rather than flee them. Says van der Kolk, "Asking her, 'Where do you feel that? How does that feel? What happens in your body when you say this?' helps her stay grounded in her body and in touch with a core part of herself; it allows her to keep her wits about her."
Later in the session, when she's standing, the woman says she feels "mushy" in her midsection, defenseless--"like, if you do anything to me I don't want, I wouldn't have the right to stop you." Gradually, without getting into the content of her trauma at all, Ogden helps the woman "fight back"--first by letting her fulfill an urge she has to push by having her push hard against her (Ogden's) shoulder. The woman looks more alive, stronger. When Ogden asks her what's happened, her hands come together in fists and this woman, who earlier said she didn't even have the right to stop someone from hurting her, now begins to release some pent-up fury: "I want to say to you that if you fuck with me, I'll kill you!" she almost hisses at an invisible attacker. Ogden encourages her to engage in a kind of mock combat--both of her hands pushing both of Ogden's hands, while Ogden braces herself on the floor. It's, in its way, a real struggle, with both woman really getting into it, pushing and grunting, and ending with both out of breath.
The effects are remarkable. The client, who's been almost palpably rigid and shrunken into herself, now is laughing, at ease, confident, even exultant. "I feel totally energized and strong," she says breathlessly. "That was really good!" A week later, she returns--a different woman--alive, open-faced, smiling. "I feel great," she says, telling Ogden that she's bought some new clothes and gone to a party. "Every day, I see a brighter face in the mirror." As for the trauma, she half shrugs and says, "What was done was done."
Van der Kolk emphasizes that at no point during this session does Ogden ask the woman to describe what happend to her. "Her problem isn't that she hasn't told the story, but that her body continues to collapse in the face of reminders of her trauma. Pat helps her stay embodied, so that she doesn't lose control of herself.
"Once you can do what you couldn't do during the trauma," adds van der Kolk, "once you can take the action you need to protect yourself, and once you're able to recenter and refocus yourself on a deep, organismic basis, you'll move on. The trauma is no longer interesting."
A Huge Debate
While some of the mainstream trauma field's leaders are intrigued by the potential in this treatment, many prominent figures are dismissive, when not positively horrified. In fact, the only issue that's generated as much heat in the trauma community has been the recovered-memory debate. Van der Kolk now finds himself in the thick of a battle that, once again, pits people of passionate convictions, high-minded purpose, and not a little professional ambition against each other.
This particular clash over the place of body psychotherapy in trauma treatment exploded at the 2000 World Congress meeting of the International Society for Traumatic Stress Studies in Melbourne, Australia. Van der Kolk himself inadvertently lit the fuse when he was asked to chair a plenary session on body psychotherapy, which featured the work and videos of several somatic therapists. One video (which van der Kolk hadn't seen) showed a practitioner sitting astride a rape victim. Although van der Kolk later repudiated this particular work, saying it exhibited serious boundary violations, the film caused an uproar. "It had a remarkable fallout," says Australian psychology professor and trauma specialist Richard Bryant. "Nearly all the major players in the trauma field were appalled by the fact that he'd used a leading trauma meeting to demonstrate a therapy like this, which was both ethically marginal and had no empirical support whatsoever. A huge debate emerged about the role of evidence in science versus the belief of many therapists that if they 'know' something works, they don't have to wait for the science to prove them right."
The "huge debate" continues to churn on. While this particular skirmish involves somatic therapy, the overall conflict is an old one, which basically reflects the division between two subcultures in the profession--practitioners and scientists. This is certainly not a "pure" division (clinicians do research; researchers do clinical work), but the world views of each differ substantially. Clinicians are immersed in the messy reality of daily clinical practice with multiply-diagnosed patients, and are often glad to try out innovations on the say-so of colleagues and on their own personal experiences that almost none would care to subject to a controlled, double-blind study. To researchers, "innovative" is often just another term for "outlandish." From their perspective, the only safe and dependable treatments are those that have been empirically proven in carefully controlled studies with homogeneous populations, that are easily put in the form of a "treatment protocol."
These differences lead to "enormous tension" between practitioners and scientists, says Bryant, a tension he believes therapists tend to use to their own advantage when they accuse scientists, as they regularly do, of being more interested in their dry paradigms than in real-life patients. "Therapists often put forward the view that the process of validating new treatments is too difficult and takes too long, in the meantime depriving suffering patients of treatment they know from experience works, just because scientists want them to do randomized trials. But, we [researchers] would argue the opposite--that because we're treating people who are in such pain, we have an ethical responsibility to make sure we aren't making them worse."
Edna Foa, one of the foremost authorities on prolonged-exposure therapy--in which traumatized patients repeatedly recount their trauma until it loses its disturbing power--is also not enchanted by van der Kolk's expedition into somatic therapy. Indeed, she suggests that the whole clinical practice of psychotherapy needs to be renovated along more scientific lines. "I think we've come to the point in the scientific research of therapy that clinicians shouldn't be allowed to practice and disseminate treatments without solid evidence that they work. Doctors can lose their licenses if they use unproven treatments. Why shouldn't we be the same way? Why allow practitioners to go wild with unvalidated therapies that may not help and can even make people worse?" Van der Kolk counters that scientific funding organizations virtually never support research in unproven treatments, thus promoting an Orwellian cycle of only advancing the exploration and practice of what is already known and closing the door on true exploration. In essence, such strictures would not only eliminate the practical insights and experience of therapists who actually see the real-life complexity of human suffering, but would put the kibosh on any original and potentially useful ideas emerging from clinical practice.
Living both in the laboratory and in the clinical office, van der Kolk has firsthand experience with the different paradigms that rule these worlds: Laboratory researchers pose a particular question they want answered, choose the subjects and methodology that will provide the best test of that question, and ruthlessly screen out any confounding variables. But "confounding variables" are the stuff of ordinary therapy. "As a clinician, you always have to listen to what your patients are bringing in, listen to what they're telling you that doesn't necessarily fit DSM categories," van der Kolk says. "It's the raw data of daily clinical practice and the variations in clinical experience that generate new research protocols."
More than just about any other field, the town-gown split between scientists and practitioners in psychotherapy reflects sharp differences in fundamental ways of taking in the world. "Skepticism is the core of scientific enquiry," says trauma expert Alexander McFarlane of the University of Adelaide. "Science is based on statistical comparisons between groups--it's not a science of the individual subject. And it's supposed to be critical--scientists make their money out of criticizing ideas. Therapy, on the other hand, happens in the realm of the individual stories people tell, and the variety of ways they do it." The therapeutic endeavor is built on a framework of reasonable trust and belief in what the patient says, not criticism. "You can't treat patients if you don't believe in what you're treating," says McFarlane. In a moment of candor not calculated to endear him to his researcher colleagues, van der Kolk says simply, "It's an issue of temperament: Therapists seem to enjoy living with the uncertainty, unpredictability, and complexity that comes with the intimacy of the relationship, whereas most laboratory scientists are most committed to establishing 'facts,' which, by virtue of the dictates of the scientific method, can only encompass a small slice of the total complexity of human beings."
But van der Kolk is nothing less than an equal-opportunity provocateur. He seems determined to make clinicians fundamentally reconsider their usual responses to the suffering souls who visit their offices, down to the furnishings they choose. With his characteristic wryness, he insists that "As long as people sit on their tochas and simply move their tongues around, they may not be able to make enough of a difference to affect internal sensations and motor actions. People need to learn to regulate their physical states in order to get their minds to work. Once they shift their physiological patterns, their thinking can change."
It's been an implicit premise of psychological science and clinical practice both, as it is of our entire culture, that our singular human identity resides in our disembodied minds. The West's infatuation with Cartesian dualism has made our bodies somehow strange to us, a self-alienation reinforced by clinical psychology. It's hard even to conceive of the lofty mind--our own, anyway--as an indisputably physical, material organ, a wrinkled, ovoid mass of blood and tissue. PTSD--or any deeply painful emotional state--is experienced as a foreign intrusion that smothers our "true self," our mind's self. Most of psychotherapy is geared to getting this mind-self back, and most of it is conducted as a mental exchange between two people sitting quietly in chairs. Even psychopharmacology seems intended more to quell the rebellious body--quiet and soothe it, get it out of the way and under wraps--than acknowledge and welcome its living presence in the therapy room.
For all the ferment he's helped create, van der Kolk admits that he doesn't have any easy answers about how to unravel the tangled web of trauma, much less reconcile our culturally enshrined mind-body split. During a presentation last year, he confessed his discomfort to several hundred therapists. "I always wonder how I can continue to do workshops like this and ask you to sit on your rear ends all day listening to me talk, knowing that people really only learn when they move and act," he says. "I feel increasingly bothered by the real contradiction between what I practice and what I preach." With his penchant for stirring things up and raising questions that can't be ignored, it's a safe bet that as long as van der Kolk feels uncomfortable with therapy's conventional wisdom, the rest of us will, too.
Mary Sykes Wylie, Ph.D., is a senior editor of the Psychotherapy Networker .