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.
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 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.
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Tags: Anxiety | Depression & Grief | Noel Larson | abuse alcohol | abuse survivors | anxiety in children | child abuse | childhood abuse | childhood traumas | Children | Children & Adolescents | compassion | complex trauma | domestic | empathic communication | empathy | guilt | post traumatic stress | ptsd and depression | remorse | sexual abuse | victim identity | violence