Q: I’m working with a Black client with developmental trauma. Whenever she tries to do her therapy homework, she has nightmares and wakes up in a fetal position. She’s apologized for this and is thinking of ending therapy because she feels like a disappointment. What can I do?
A: It’s not easy when clients who we feel have more work to do in therapy tell us they want to stop. It can be even trickier when their leaving seems tied to their relationship with us.
However, as upsetting as it may be, your client’s brave confession could ultimately be a gift. She’s offered you an opening to explore how your work together has activated a traumatic threat response. Perhaps if you can openly address this, you’ll be able to uncover some pivotal truths and map a better path forward.
It sounds to me as if your client’s been experiencing a powerful threat response of submit and collapse, followed by the less-discussed response of appease. She’s tried to appease you by overriding the overwhelming distress of doing the homework, at a great cost to herself. Now that the appeasement isn’t having its hoped-for effect, the shame that’s arisen may be driving her away from you.
It’s also likely your client feels threatened and overwhelmed by the treatment process and, I’m sorry to say, possibly also by her relationship with you. She may’ve been trying to manage this with a variety of threat responses for a while.
Race and Appeasement
Each human threat response entails survival strategies that we use when we feel we can’t get to physical or emotional safety. As a Black woman and a Black therapist, I know a lot about the threat response of appease, both personally and professionally. I also know there’s a price that I often pay when I use appeasement to manage threats.
We usually think of fight, flight, and freeze, and even submit and collapse, as reflexive. Often, other people will validate those threat responses as appropriate—even necessary—because they operate at a biological level beyond our conscious control. But we make a choice to appease someone who’s threatening us, and thus this appeasement is often cloaked in shame.
Appeasement is an especially common threat response for BIPOC and marginalized people, due to their experience of historical trauma and the reality that they’re often on the bottom rung of the power hierarchy in today’s world.
Since taking a training that dove into appeasement, I’ve been wading through my own memories of reverting to the appease response. Just like any other threat response, I’ve noted that when I’ve appeased, my nervous system has been in a state of high sympathetic arousal, which can feel out of control because of the presence of threat.
All my appease incidents are laced with a sense of shame and involve people I perceived to be in a position of power. Sometimes the shame of responding with appeasement feels huge, like a clap of thunder; and sometimes it reverberates as a muted echo long after the actual incident.
It echoes after I remind my daughter to say as little as possible and never argue with a police officer if she’s stopped while driving. It echoes each time I hold my tongue in professional spaces, rather than be the mythical angry Black woman, or whenever I wait patiently to be seen and heard in ways acceptable to those in positions of power.
Shame came as a thunderclap years ago, when I chose not to fight back when a white, male psychotic patient physically assaulted me. I was working in a partial hospitalization program at the time, was physically trapped, and did what I needed to do to survive. Yet the shame still courses through me, ancient and powerful, and steeped in my own cultural and intergenerational trauma. I think to this day, “How could I have let him hit me?”
Underlying these experiences of shame is powerlessness, with an existential sense of being utterly alone. As with all threat responses, appeasement is an attempt to gain more power, privilege, control, connection, or value, as well as to escape or survive the threat. But there are many times when it doesn’t grant us any of those things. When you do all you can do to appease and it doesn’t work, the shame deepens.
In terms of your client’s developmental trauma, it’s fairly safe to assume that on top of any of the abuse, emotional neglect, or isolation she experienced in childhood, she likely, as a Black woman in America, has an intergenerational history of cultural and historical trauma.
Though you can be pretty sure about those things, I’d still be curious about them and ask her directly about any intersecting traumas.
Appeasing the Therapist
I’d consider the possibility that your client continued to override her activation with the homework because she was afraid she’d lose you, or you’d disapprove of her. We need to make it clear to our clients that they can tell us to stop when the work is beyond their window of tolerance, and they won’t be labeled resistant or manipulative. If your client has been mandated to attend treatment in some way, the power differential and that sense of threat increases.
If I were her therapist, one thing I’d ponder is whether her compliance felt, on some level, more pleasant or safer for me. Might I’ve had an inkling that topics were being avoided to steer us away from conflict, or from my own vulnerability or discomfort? We always need to ask what we ourselves are carrying that keeps our client connection at bay.
With complex clients, I can find myself reacting and responding to intense emotions or states of overwhelming activation by avoiding them, or trying to make the client feel better, or challenging what I might think are cognitive distortions.
When we’re afraid, we may also try to control clients’ behaviors by challenging their thoughts. This usually increases their activation and their existential sense of being alone. I’ve noticed that when my clients move toward toxic shame, I can get anxious that they’ll spiral down into a trauma vortex of unmanageable activation or even self-harm. I’ll then automatically move toward making them feel better, challenging their negative sense of self, or pulling out the safety plan when what’s really needed is a well-regulated other—someone who can stay attuned with them in the midst of their pain.
Dig into Identity
Some of what we’re carrying into our therapy relationships may have to do with unaddressed issues of identity: color, race, ethnicity, culture, gender, sexuality, wealth, class, and age. Bringing awareness to those identities can lead to conversations that cocreate safety within the therapeutic relationship. Do we tend to merge with familiar identities or disengage with difference? We must hold in mind the histories of trauma, pain, and loss in ourselves, and in each of our clients.
Years ago, I started working with a middle-aged Black man mandated into treatment by the legal system. He was referred to me by his group therapist, and when he laid eyes on me in the waiting room said, “I thought you were going to be an old white woman.”
This comment wasn’t simply about race. It was about connection, power, and threat. It was the attachment cry of, “Will you see and hear me? Will you understand my pain?”
Before I could move on to what had landed him in my office, he had to have a sense that I understood his life. He needed to feel that whatever the truth of his actions, I’d value him as a human being and share enough power with him in the treatment process that he could acknowledge his misdeeds, repair his relationships, and make amends for any harm he may have caused. He had to know that I’d be the kind of ally that could always hold the hope and the possibility of healing.
I had to meet that attachment cry with my presence.
In your question, you mention several locations of your client’s identity: Black, female, and developmentally traumatized. How do you sit with each of those?
I once had an older white female client who grew up with a lot of intergenerational wealth. Our locations of race, ethnicity, and class were quite different. Early in our relationship, I asked her, “What’s it like for you to have a Black therapist?” She paused, then said, “What’s it like for you to have a white client?” What a wonderful response!
There’s power and benefit in acknowledging what’s already present. If we know we occupy different locations of identity, our clients know it too. Let’s have transparent conversations about it, so we understand what that means for the therapeutic process.
Getting back to your client, you’ll want to remind yourself that your job is to reduce the threat that’s causing the appease response, and increase regulation and her tolerance for the treatment process. To do this, I’d back up, slow down, process smaller pieces, and work on expanding her resources for regulation and connection as you go along.
The first part of this effort might be to say that you’re so sorry the process has been so painful for such a long time, and to reassure her that all her parts are equally welcome, including the parts that don’t want to do the homework. I’d thank her for telling me now, and validate how difficult that might’ve been for her.
I then might gently invite her to notice that what she was afraid might happen if she’d told you how unsafe she’d felt doing the homework wasn’t actually happening now. I’d go slowly with this piece to give her time to integrate that reality.
I’d then be curious about the threat of doing the homework, and what that experience is like for her. I might gently invite her to ponder how parts of her are experiencing me. My guess is that waking up in a fetal position on the floor indicates that she has a young part that gets really activated by the homework. I’d want to know about the part of her that overrides any high-intensity activation to get the homework done.
Then I might try some experiments. For example, is it safer to talk about the homework or write it out with me in session, rather than doing it when she’s alone? We might try to strengthen her capacity to recognize when she’s becoming overwhelmed beyond her window of tolerance. Perhaps we need to build her capacity to validate her own boundaries and limits and to know when she needs to say stop and no.
Your client is a complex being. I always say that we must design each treatment with a complexity that meets, or even exceeds, the client’s complexity. But the good news here is that your client isn’t broken. She’s been wounded for sure, and she can heal. She had the wherewithal to confess what’s been happening and discuss her desire to stop working, rather than just disappear.
I always remind myself that no matter how complex or daunting the work is, my job is to stay open to the possibility of healing. And with your client’s recent honesty and your clear concern, the two of you have a promising invitation to engage that possibility now.
Photo © iStock/tommaso79
Anita Mandley, MS, LCPC, practices at the Center for Contextual Change, where she focuses on clients who’ve experienced trauma. She’s the creator of Integrative Trauma Recovery, a group therapy process for adults with complex PTSD.