My grandchildren often call me a dinosaur as I stumble along through the 21st-century digital world they navigate so easily. I pretty much like being a dinosaur, attached to my old-fashioned ways of doing things—except for the part about being extinct. Nevertheless, that’s sometimes how I feel when the therapists I supervise start talking about all the new trauma treatment approaches they’re learning, as if relationship-based verbal therapy is no longer relevant.
At the core of my work is the ability to connect with clients and form a bond grounded in compassion, empathy, and close attunement to the unfolding of the therapeutic relationship. That’s something that most therapists find relatively easy to do with the usual trauma clients—hyperaroused people who don’t have much difficulty communicating their vulnerability and emotional sensitivity. But it can be a lot tougher to remain nonjudgmental and receptive with dissociative clients, who are quick to challenge, criticize, diminish, and resist the clinician’s attempts to be helpful. Such individuals may appear void of tender emotions like sadness, fear, anxiety, and especially love. And then there are some even further out on the extreme of the human spectrum: deeply troubled, unattached people, who victimize others and may have done horrific things that test the capacity of even the most openhearted therapist’s ability to extend compassion and acceptance. But it’s in working with this population that we can learn fundamental lessons about trauma work and the possibility of transformation, even for those whose cruelty and indifference to the suffering of others seem to take them beyond the reach of psychotherapy.
We know now, without a doubt, that trauma affects the developing nervous system. When the primary caregiver is unwilling or unable to regulate an infant’s stress through attunement, the child suffers extreme anxiety, even terror. The child who doesn’t get the message that everything’s going to be all right can grow up unable to regulate his or her own affect. Without attunement, the infant’s brain has two major options: hyperarousal or dissociation. A hyperaroused child’s world is dominated by hypervigilance, emotional reactivity, and vulnerability to intrusive imagery. A more dissociative child experiences the numbing of emotions, diminished sensation, disabled cognitive processing, and lack of empathy. Chronic victimizers are overrepresented in this latter category.
Throughout my career, countless people have asked me how I can work with clients who’ve committed sexual abuse, murdered their wives, or broken their children’s bones and spirits. My answer has always been the same: all I have to do is remember and feel in my heart the traumatized children my clients once were. If I can find within myself empathy for their own traumatizing childhood experiences, I can discover a way to put aside my own horror and revulsion at their behavior and access the qualities within myself that I’ve learned are central to fostering healing in others.
Making the Connection
Early in my career, when I first began doing group therapy with incarcerated female sex offenders, I wasn’t sure I’d be able to open my heart to them. I was working with a dozen women in group therapy, all of whom had sexually abused children, most of them their own. In the hours they spent recounting their histories, it was easy to understand how they’d ended up as they had. One woman, named Selena, told the group that after her dad had left her mother when she was five, she’d lived in a car with her mom for several years. To support herself and her child, the penniless mother had turned tricks in the car for money for food, even allowing Selena to be sexually abused by men who preferred children to adults.
Eventually, Selena was removed from her mother’s custody and placed in foster care, only to be sexually abused by her foster father. When she turned 17, she ran away from home with an older man and had two children, a boy and a girl. Over time, her husband began molesting their young daughter and threatened to leave her without any means of support if she refused to become sexually involved with their young son so he could watch. She complied until the abuse of her children came to the authorities’ attention. At 23, she was sentenced to 12 years in prison.
We now know how the basic capacities that make human relationships possible can be arrested when a child is traumatized. This was chillingly borne out for me one morning when I asked each woman to tell the group her age—not her chronological age, but how old she currently “felt” herself to be. The responses ranged from ages 2 to 15. Later, as my cotherapist and I processed the session, we realized that each woman’s “felt” age was within a year or two of her own sexual abuse as a child, as well as within a year or two of the age of her victim. So the 19-year-old who said, “I’m two years old,” had been sexually abused as a toddler, and went on to sexually abuse a neighbor’s two-year-old boy. And the 18-year-old, who, in a fit of jealousy, violently raped a 14-year-old girl with a broken coke bottle, had been gang-raped herself as a 12 year old, causing substantial damage to her genitals. Her brother, a member of the gang, had set up the rape to solidify his position in its leadership.
All the women in the group started out pretty well defended, both from themselves and each other. Since child sex offenders comprise the bottom of the pecking order in any prison, they assumed that my cotherapist and I would treat them the same way as some prison staff and many other inmates—with contempt, ridicule, harassment, and confrontation. Instead, they were met with the freedom to talk about anything without judgment from my cotherapist or me. Gradually, their defenses came down, and many sobbed as they began to talk about their lives—not about being put in prison, but about their excruciatingly painful childhoods. Eventually, they could even grieve the loss of their children, having allowed themselves to feel a sense of attachment for the first time through their participation in the group.
Several of the younger women said they wished I or my cotherapist had been their mother. One woman, imprisoned because she’d shot her sleeping husband, asked me to hold her while she cried. She’d been removed from her parents after being sexually abused by her father, lived in multiple foster homes, and married a violent older man. Another young woman, who’d sexually abused a developmentally disabled man and was often put in segregation for acting out in prison, told us that she finally knew how it felt to be loved. Without experiencing this sense of deep connection with us, these women would likely have continued to abuse others, regardless of how many hours they logged in therapy. Empathy is a critical element in reducing recidivism, and it can’t be prescribed or taught. It first must be experienced from another person. Only then can it become a base for behavioral control in dealing with others.
Therapist, Soothe Thyself
I remember a session supervising a child protection worker that indelibly demonstrated what happens when we lose our capacity to connect and empathize with clients. The client, Corinne, had temporarily lost custody of her two young children, who’d been sexually abused by Corinne’s boyfriend, and they remained in foster care. Sophie, my supervisee, also the mother of two young children, was frustrated by Corinne’s failure to follow the judge’s orders to facilitate reunification. She rarely visited her kids, and when she did, she spent little playtime with them.
In counseling, Corinne made no eye contact, and with arms defiantly crossed said, “Why should you care if I visit my kids? I might as well let go of them now, since the judge is going to take them away forever anyway.”
Exasperated, Sophie snapped, “What kind of mother are you, anyway? Why don’t you fight for your kids?”
At this point, I called Sophie to meet me and the members of her child protection team behind the one-way mirror. I told her that I could see and hear her frustration, and that I believed Corinne was reacting in such a defensive, resistant manner because she felt threatened by Sophie’s stance. As difficult as it sounded, I asked her what she could find to love about her client.
Between clenched teeth, Sophie said, “I want to scream at her, not love her!”
But a colleague of Sophie’s reminded her that just a few weeks ago, Sophie had felt empathy for Corinne when she’d learned that Corinne’s boyfriend had been critical of her weight, just as Sophie’s husband had been of her own, leaving her feeling unattractive and unloved. At this point, I asked Sophie to close her eyes, calm herself, and focus on feeling whatever compassion she could for Corinne. Then she walked back into the room.
The tenor of the whole session changed immediately. Sophie calmly said, “I can understand how painful and terrifying it must be to think about losing your kids forever. It’s heartbreaking even to think about it. I believe we can keep that from happening. We can bring those kids back to you if you can let yourself trust me. I’m here to help you, not hurt you.”
With tears in her eyes, Corinne said, “I’ll try. I don’t want to lose my children.”
Soon, they were planning Corinne’s visits with her children together, which over the following weeks took place with increasing frequency. Although there were some bumps in the road, it was as clear a demonstration of the idea that genuine empathy is the major antidote to client resistance as I recall seeing.
Effective therapy requires us to track both our own moment-to-moment internal states and those of our clients. Once we get reactive or judgmental, we can easily break whatever fragile connection we’ve managed to forge. We’ve all been there, listening to a client while marshaling our next set of statements to counter, feeling our breath getting shallower and our heart beating faster. When I start moving in that direction, I repeatedly say to myself, Larson, get a grip, which I’ve learned to use as a signal to deepen my breathing. As my brain and body quiet down, I become able to resume the process of tracking my internal sensing while increasing my receptivity to my client.
Therapist hyperarousal isn’t the only way to lose contact with a client. We can also fall prey to what I call normal dissociation. For me, it emerges from a variety of internal states: I might be preplanning for a difficult session that’s coming up, or I’m tuning out to my client’s umpteenth replay of the same story, or I’m distracted by a comment that triggers a memory of something in my own life, or I’m simply tired. As subtle as this kind of fuzzing out might be, with their ultrasensitized emotional brains, developmentally traumatized clients instantly notice that I’m no longer attuned. If it happens often, I can expect them to start missing appointments or simply stop showing up altogether.
A Safe Distance
Many people along the perpetrator spectrum have never committed a crime. They include narcissists, whose developmental wounds keep them from being able to reach out beyond their own experience, and civilized sociopaths, who were emotionally abandoned as children. Greg, a well-educated and successful corporate executive, was an example of this kind of high-functioning client. He came to see me because he was in the middle of a messy divorce and wanted my help retaining custody of his young daughter. Calm and unflappable, he wasn’t the kind of man who easily asks for help. Although he was losing his second marriage, it was as if he was just dumping a used car. He also had distant relationships with his two adult children, whom he’d barely seen since the divorce from his first wife. While he seemed somewhat connected to his 10-year-old daughter, I wasn’t sure whether his caring was genuine, or if he simply wanted to pay less child support to his soon-to-be ex.
To see if I could penetrate his dissociation, I said: “Tell me about the first time you remember your heart being broken.”
Gazing at me with a faraway expression, Greg told the story of how as a young child he and his family regularly spent summers in a cabin in the country. His mother would stay with him and his older sisters, while his dad would commute in on weekends. One Saturday afternoon, he was startled to see his parents driving away from the cabin, their leave-taking and destination unannounced. His sisters soon went with friends to another cabin, and he was left alone. In the course of playing with a gas canister, he accidentally ignited it. On fire, he ran screaming to a neighbor’s cabin and he was rushed to a local hospital, his leg badly burned. During his month-long recovery in the hospital, his father came by to visit him after work a couple of times a week, but his mother never visited. At the time, Greg was nine years old.
He showed little emotion as he reported the incident to me. Then he pulled up his pants leg to show me the massive scars left by his accident. “Those are big scars,” I said. “But they’re nothing compared to the scars on your heart from your mother abandoning you after such a horrible experience.” I told him how sad I felt about what he’d gone through, not only about the physical pain of his burns, but being all alone in the hospital at such a young age. He barely reacted to my words.
Several days later, however, while I was on vacation in another state unable to meet with him, Greg called me on my cell phone. “I’m in so much pain,” he sobbed. “I can’t stand feeling like this. I feel like I’m going crazy.”
I connected his deep pain and sorrow to our conversation about his severe burns and lonely recovery, something that he hadn’t yet done for himself. “As a child, alone and unsupported, you had to shut yourself off from your feelings to cope on your own as best you could,” I said. I told him that now his body was finally expressing the buried emotions of his nine-year-old self. This calmed him somewhat and he agreed to reach out to his sisters for support. When we met again, I continued to connect his early experience of abandonment to his history of being unable to attach to his children or his wives in meaningful ways. He continued to share his long-disowned grief with me, especially his painful alienation from his mother, now deceased.
As he learned to tune into himself and his relationship with me in a different way, Greg eventually decided he wanted to clean things up with his adult children, whom he’d alienated over the years. In sessions with his oldest daughter, he faced her anger and grief over his absence from her life. As he committed himself to becoming a real part of her life, they made a plan for contact, and kept it. It’s been several years since those sessions, and his daughter, who’d previously seemed aimless and uninterested in attaching to anyone, finished college, got a good job, and started a meaningful relationship with a caring man.
Connecting with his son wasn’t so easy. Still bitter over being left to take care of his depressed mother after his parents’ divorce, the young man angrily rejected his father’s attempts at reconciliation. Nevertheless, Greg continued to reach out, often just leaving messages for his son, saying that he was thinking of him. It took several years, but one day Greg’s son called and set up a dinner with his father at a restaurant. As they were leaving, for the first time in Greg’s memory, his son said, “I love you, Dad.”
I’ve seen many clients who first began to open up to me and then to the other people in their world by reconnecting with the walled-off pain from the past. Certain questions often provide a pathway for people to recognize that their emotional deadness is connected to painful events in their lives. Such questions include “When did you decide you’d never be hurt that badly again?” and “How old were you when you knew you had to be on guard all the time?” and “Do you remember the first time your brain managed to remove you from the terrifying situation?” I’m consistently amazed that even my most emotionally dissociated clients often know exactly when it happened. Typically, they spill out their story, which I respond to with genuine empathy and sadness. Then, I wait. Sometimes it takes only minutes for clients to emotionally connect and erupt into sobbing; other times it takes days or weeks. I may even have to revisit the experience repeatedly with them. But one of the rewards of trauma work is to see, once the connection with the past is made, how the hijacked process of normal developmental can restart itself.
“Your Story Makes Sense”
Individuals who’ve been traumatized as children continue to experience deep shame in the present, believing that the bad things that happened to them must be their fault. But this deep-seated belief took hold in their early years as a means of survival. If a child believes he’s the problem and his parents are not, he probably has a better chance of being fed, sheltered, and kept in the family than if he confronts them with their ineptness. Keeping this in mind, one of the most powerful interventions with developmentally traumatized clients is the positive reframe, which allows almost any behavior—however strange or self-destructive it may be—to be understood in the context of early experience.
I was recently asked by a prison to consult on a difficult case involving a young inmate named Lewis, who’d repeatedly tear open his abdomen with whatever implement he could find and create infections by stuffing the wound with dirty materials, including human waste. Although the prison administration would arrange medical treatment for him, once released back to his cell, he’d tear out the stitches or staples and repeat his attempts to infect the wound. Some of the prison authorities hypothesized that his self-injurious behavior was designed to give him time away from living in segregation, where he was confined for 23 hours a day with little human interaction, but an astute prison psychologist thought the problem was far more complex than catching a break from segregation.
After reading his several-inch-thick criminal history, I asked to meet with Lewis personally. His records indicated that his mother, who’d become pregnant with him as a result of a rape, had paid him little attention before voluntarily terminating her parental rights when he was six. Subsequently, he was sent to a foster home, where he was physically abused. Next, he was placed in a group treatment facility, where older boys sexually molested him. From then on, he was in and out of juvenile corrections institutions for petty crimes: shoplifting, car theft, purse snatching, and eventually burglary.
When I came to the prison to meet Lewis, he seemed eager to talk. After telling him that I’d read a great deal about him and felt considerable sadness for his traumatic life history, I asked if he’d talk with me about his self-injury. Giving him a choice to talk or not to talk about himself seemed to please Lewis. I then asked him if his cutting was an attempt to avoid feeling emotional pain by converting it into physical pain, a common reason for self-injurious behavior.
Lewis looked at me, genuinely puzzled. “No way,” he said. “I do it because I’m trying to come back to life.” He explained that he could only tolerate about three months of confinement before he started to feel like he was dead—an experience he found intolerable. Through trial and error, he’d learned that it took a lot of physical intrusion to bring him back into his body. “It’s like I wake up,” he said. “When you hurt that much, man, you know you’re not dead.”
This is the way I frame all self-injurious behavior for my clients—they’re taking extraordinary measures to do something for themselves so that they can survive, either by physically associating or by dissociating emotional pain that’s intolerable, as was the case with Nate. Although convicted of murdering his wife and young son, Nate was a model inmate, compliant with all the demands of prison life, and well-liked by the prison treatment staff. During his 20 years of incarceration, however, he’d always maintained that he’d kill himself when he was released. Noting his upcoming parole, the staff asked if I’d consult with him to see if I could help him leave prison wanting to live.
After joining Nate’s therapy group one morning and listening to considerable discussion among the leaders and inmates throughout the hour, I noted aloud that Nate had remained silent.
“Oh yeah, he never talks,” said one inmate.
“Would you be willing to share something?” I asked Nate directly. “I’d really appreciate hearing something about your history.”
Nate told me that he grew up on a Native American reservation surrounded by violence and alcoholism. When Nate was quite young, his father, brother, and several members of his extended family had all died untimely, violent deaths. On the day he shot his wife and son, he’d learned that his mother, his only surviving relative, had been diagnosed with terminal cancer. “I just went crazy,” he said. Then looking away, he whispered, “I need to die for doing such a terrible thing.”
I was quiet for a few moments, and then I told Nate that I could understand why he did what he did. Death had taken nearly everyone in his life he cared about and he wasn’t going to let it do so anymore. “You were going to defeat and master death by taking control of it,” I said.
The inmates around the circle erupted, protesting that I was telling Nate that it was okay that he’d murdered his family. But I told them that I wasn’t condoning his actions; rather, I was simply explaining that what he did in the context of his life story made sense. The men continued to object. Nate remained silent.
Later that day, I was notified that Nate was shrieking in his cell, alternating between rage and intense grief. This was the first time the staff remembered him ever expressing these kinds of emotions, and they were worried. I told them that Nate was finally feeling all the unexpressed grief and rage that he’d accumulated over his lifetime but had never allowed himself to experience out of deep shame for what he’d done. I encouraged them to support and comfort him, and to continue to keep him safe until his emotions subsided. Three months later, he was released from prison. A year later, he was still alive.
In telling Nate and the others in the group that his story made sense—yes, even the horrifying part, where he murdered his own family—I was in no way excusing his behavior or giving him a free pass because he himself had been traumatized. Instead, by helping him take the necessary first step in facing his experience of abuse and abandonment, I was making it possible for him to take responsibility for the pain and suffering he’d caused others.
Working with people with personality disorders requires us to confront the phenomenon of dissociation, the brain’s way of protecting itself from feeling crushed by a constant sense of overwhelming danger and imminent catastrophe. While dissociation in all its forms clearly has survival value for developmentally traumatized individuals, it also leads to developmental dead spots—areas of personality development that are stuck in a time warp that coincides with childhood experiences of trauma.
Since empathy is developed through secure attachment and attunement, abused and/or abandoned children may never learn how to use their own painful experiences to understand what it’s like for another person to go through a similar experience. They may grow up without internalized brakes for causing pain and harm, or what we commonly call a conscience. While most people are capable of doing hurtful things to others, including people they love, personality-disordered people lack the fundamental capacity for recognizing the impact of their hurtful behaviors on others, and they suffer from the inability to feel guilt or remorse. Those developmental deficits separate clients who can be more easily treated with direct approaches from those who require a much slower, more remedial therapeutic approach.
When I describe my work, people often ask how I get clients who’ve been perpetrators to take responsibility for the pain and suffering they’ve caused. My reply is that it’s not a terribly difficult task, once their developmental dead spots have begun to come alive. For that to happen, however, they must experience my being reliably attuned and empathic toward them in the therapeutic relationship. After all, a person can’t develop the capacity to accept responsibility for having done harm without first having had the experience of being the object of empathy and care from others. Once that capacity is developed, the sense of inner deadness can become transformed, allowing that person to focus on grieving the losses that were never previously acknowledged.
In other words, by connecting with people who’ve done horrendous things, I’m not letting them off the hook. Instead, I’m welcoming them back into the human community and making it possible for them to truly take responsibility for the harm they’ve done. It’s only when that threshold has been crossed that they can experience true remorse, make genuine apologies, ask for forgiveness, and—where possible—make amends to those they’ve harmed.
Of course, treating clients with personality disorders isn’t for everyone. It requires an ability to be present in a moment-to-moment way that, over time, melts resistance and fosters a revised attachment schema. Without this, any behavior change will be a performance on the client’s part, rather than a truly integrated change. It’s work uniquely suited to dinosaur therapists willing to be open, compassionate, nonjudgmental, and often vulnerable with people most of the world chooses to steer away from. Nevertheless, the new neuroscience of my profession confirms what “dinosaur therapists” have believed all along: just as in parenting and other kinds of meaningful human relationships, there’s no shortcut to the attunement and empathy that lie at the core of emotional connection and healing.
Illustration © Carol and Mike Werner / Phototake
Noel R. Larson, PhD, MSW, is a licensed psychologist, marriage and family therapist and independent clinical social worker. She maintains a private practice at Meta Resources, a clinic she co-founded with James Maddock in 1981. Dr. Larson also provides supervision and consultation to groups throughout the country and conducts training workshops in the U.S. and abroad on personality disorders, family therapy, resilience, sexual abuse treatment, systemic treatment of domestic violence, group therapy, trauma and attachment and the therapist differentiation. Dr. Larson is the coauthor of Incestuous Families: An Ecological Approach to Understanding and Treatment (Norton). As a consultant to a domestic violence treatment program, her and Dr. Maddock’s systemic model was featured on Oprah, as an alternative to the cognitive-behavioral anger-management model.