Mary Jo Barrett
By Mary Jo Barrett
Over the past 35 years, the trauma field has seen the emergence of powerful therapeutic innovations like eye movement desensitization and reprocessing, Somatic Experiencing, dialectical behavior therapy, and Internal Family Systems, as well as many major advances in our understanding of the brain and the neurobiology of trauma. Clearly, we’ve made important strides in our ability to help overwhelmed and hopeless people overcome the stigma previously attached to trauma symptoms, learn new thinking and self-regulation skills, and even find a new sense of restored well-being---at least for the period of time that they’re with us in our offices.
But then they go home, and far more often than we’d like, when they’re back in their daily lives with family, friends, and coworkers, they don’t do so well. In fact, no matter what progress they make in therapy, once they leave the safe, rarified space we provide them in our treatment rooms, they frequently fall right back into the same old patterns of negative emotion and dysfunctional relationships.
Let me give you an example. Lucy, a therapist I supervise, recently came in to discuss a difficult case. Her client, Abbey, a 46-year-old woman, suffers from severe anxiety and depression, abuses prescription drugs, purposely harms herself by hitting herself all over her body and head, frequently quits or is fired from jobs, and regularly alienates the few friends she has. Like many trauma sufferers, she’s easily triggered by her interactions with just about everybody she knows, especially her husband and two teenage children, who she says are “miserable, nasty human beings.” At home, she fluctuates between furiously attacking them---yelling hateful remarks, throwing things---and withdrawing into a sullen shell.
During sessions, Abbey dissociates while talking about her life, past or present. But through Lucy’s guidance and skill, she’s learned and practices many mindfulness techniques that have enhanced her ability to recover and bring herself back into her body when she shuts down. Most days when Abbey leaves therapy, she’s calmer, exhibits some genuine insights into herself and her problems, and often seems to be discovering an embryonic, but real, sense of inner selfhood. By the next session, however, it’s as if she has amnesia for all that transpired in the previous week. So she routinely begins each session, week after week, in varying states of anger, despair, dissociation, hyperanxiety, or rock-bottom depression. The therapy is still stuck.
Most clinicians believe that the benefits of individual therapy should naturally transfer to the rest of a client’s life. But what if that’s not necessarily true? What if the positive interactions a person has with a therapist in the “inside” world of the consulting room don’t translate into the language of relationships conducted in the “outside” world of the person’s everyday life?
After having his wants and needs being given weight and importance by the therapist, the client must face, all alone, those immovable other people at home who have their own wants and needs—often at odds with the client’s. It shouldn’t come as a surprise then that some clients come to firmly believe that no one at home understands him, feels for him, or has the patience to just listen to him.
Meanwhile, family members instantly pick up on the invidious contrast in the client’s mind between the wonderful therapist and their un-wonderful selves. Steve’s wife, for instance, might look at him, back from the therapeutic love-fest, and wonder, “Is he talking about me in therapy? What’s he saying? Why does he always seem to be in a worse mood when he gets home? Does he blame me for everything?”
To some family members, the client’s therapy can even feel like a kind of infidelity, triggering their own insecurities, anxieties, and even panic. As they see it, my mother, my sister, my husband, my child is experiencing a powerful attachment to someone outside the legitimate home ties. In essence, the client implicitly communicates to the therapist, Only you understand me; only you are there for me, which the family members pick up on as a rejection of them in favor of a better, kinder, wiser, more loyal significant other than any of them could ever be.
Here’s the real problem: no matter how much we help our individual clients better understand themselves, recognize their own stumbling blocks, and use new skills to rebuild themselves from the inside out, we haven’t woven change into the fabric of their daily lives, the ones they share with people who aren’t their therapists.
Bringing the Outside In
Clients, especially those who’ve been traumatized, often feel disconnected from themselves and somehow separate and cut off from other people, including members of their own families. Unfortunately, our one-on-one approach to treating them perpetuates this experience of being “other” in their daily lives---being the victim, the sick one, the outsider who’s not understood, validated, or welcomed, even in his or her own home. By implicitly emphasizing their separate and isolated status in therapy, we contribute to estranging them even more from the relationships that mean the most to them.
From the family therapy perspective, we’re always skating on thin ice when we fail to include the key players in the client’s life---the people who help them feel safe and secure or, conversely, make them feel insecure and threatened. Often, of course, these are all the same people.
So what are the concrete clinical advantages of taking a more systemic approach to the treatment of trauma? When the relationships of our clients are enacted right in front of us, we have a much more realistic view of what’s happening at home, what’s triggering their traumatic symptoms, and what’s helping or hurting their ability to function. With a systems approach, we’re not just hearing stories about people, but actually experiencing them ourselves, feeling in our own bodies what happens between people and seeing the patterns acted out.
So why are trauma therapists so often hesitant to integrate family and couples approaches into their work? Why, more often than not, do they choose the safe haven of individual therapy, even when it has limited impact on interrupting and changing the negative interactional cycles that keep both trauma survivors and their families retraumatizing each other? Mostly, I think we avoid families because they can be so exhausting, creating an atmosphere of great emotional volatility, which requires us to be on our toes all the time. But beyond the inconveniences and emotional challenges of systems approaches, I believe the overriding reason that they’re not used more is that our professional training doesn’t encourage us to expand our vision of our clients’ lives and their pathways to healing beyond their individual selves. In addition, too many of us naively accept our clients’ limited versions of the other people in their lives, or we listen to the opinions of referring sources, blind to family members’ strengths, as well as their failings. Creating healing partnerships among the people our clients interact with every day can’t be done in individual therapy. Nor can it be done at home, since it takes a safe environment to recognize destructive cycles and discover ways to interrupt them. This is especially true with trauma survivors. As they share their deepest feelings and narratives, they’re emotionally held not only by the therapist, but by the people who are most important in their lives.
The therapy experience takes on an entirely different dimension when family members learn to be healing agents for each other. As Carl Whitaker once asked, “Who would you rather get a hug from, your mother---at least after she realized the meaning of a real hug---or your therapist?”
This blog is excerpted from "Outside the Box" by Mary Jo Barrett. The full version is available in the May/June 2014 issue, Treating Trauma: What Are We Missing?
Read more FREE articles like this on Trauma.
Want to read more articles like this? Subscribe to Psychotherapy Networker Today! >>
Illustration © Dave Cutler