The Perpetual Student


The Perpetual Student

A Trauma Treatment Journey

By Janina Fisher

November/December 2021


In 1987, I was more than halfway through a doctorate, working as an unlicensed counselor in a psychiatrist’s practice. Catherine, my new client, was sitting in the waiting room, looking like someone carrying the weight of the world on her shoulders. Her hair was pulled back, and tears were running down her face. It would be another two years before I’d meet trauma-work pioneer Judith Herman—so I didn’t think trauma when Catherine told me about her childhood, how her single mother had depended on her to be the adult in the family, how her depressed father had been emotionally unavailable, and how her grandmother—who took on a parental role out of necessity—had been fiercely stern.

But Catherine wasn’t in my office because of childhood neglect; she was there because her husband, Abe, wanted to end their marriage—to “be free” as he’d put it. She was overwhelmed, brokenhearted, distraught, and unsure how she could go on without him.

They’d been married for 10 years and had two sons. Catherine was the family breadwinner. Abe was a free-spirited Peter Pan, capable of making a good living but unable to find a job that would allow him to come and go as he pleased—or do what he pleased. Despite his childlike disposition, she described his presence as her rock. Clearly, he represented the family she never had growing up, but when I made that interpretation, as my psychodynamic training had prepared me to do, it precipitated a new flood of tears and wailing. “What will I do now? How can I live?” she cried.

The more I heard about Abe’s behavior, the more I believed my role was to help her say goodbye to this man, whose symbolic meaning far outweighed his actual contribution to her life. He went out late at night with no explanation of his whereabouts, had little patience for her tears and fears, often forgot to pick up the children after school, and liberally spent the money she earned.

I tried to help her see how little he brought to the relationship, but that just evoked more tears. Within a few months, she began talking about suicide as the only answer, saying things like, “I don’t want to live without him!”

Week by week, her conviction that suicide was the answer became stronger. Looking back, I realize she was experiencing what I call a “long, slow flashback,” emotionally reliving the years she’d felt abandoned, alone, and unwelcome. Today, I’d recognize her fear, grief, and despair as feeling memories rather than as situational. I’d understand her suicidal ideation as the only option imaginable to a little girl in a world in which she had no control.

Instead, week by week, I became increasingly anxious. I understood suicidal ideation as a determination to die, rather than a way to self-soothe. I was too new to the role of therapist to know what to do with suicidal clients other than to check in with them and make sure they were still alive. That’s what my colleagues and supervisor recommended: keep asking her to contract for safety and keep checking in.

"It was a mistake of the heart to cut Catherine off suddenly and change therapeutic frameworks without explanation—on the phone, no less."
PHOTO © ISTOCK/URBANGLIMPSES

Catherine welcomed the check-ins and soon began seeking them out, calling me throughout the day whenever she became overwhelmed. The more contact I offered, the more her need for contact seemed to grow. But I reassured myself that at least she was still alive.

Feeling a bit desperate for advice, I joined a peer supervision group of psychiatrists and psychologists at a local teaching hospital. It was there that I learned about a different approach, espoused by Otto Kernberg, for what we then called borderline clients. Kernberg recommended that the therapist keep a tight treatment frame to limit borderline clients’ “manipulative, attention-seeking behavior.” In those years, we didn’t think about trauma or posttraumatic triggering or implicit memory or autonomic dysregulation. We thought about the unconscious and attachment, but not about the brain and nervous system. Kernberg’s theory blamed the client for the difficulties in treatment.

I’d never thought of Catherine’s crises as manipulative or attention-seeking, but the more the group of senior, mostly male mental health professionals pushed this perspective as the only way to think about her, the more tired I grew of the daily check-ins. If I thought of them as necessary for successful treatment, it was a small price to pay. But if I thought about them from a Kernbergian point of view, they were stressful, inappropriate, and intrusive.

After two years of treatment, I decided to respond to Catherine as Kernberg advised. In 1989, we didn’t have cell phones, but we did have pagers. Ironically, Catherine paged me just I was preparing to leave the hospital after the end of the peer-supervision group meeting. I can still picture the little hospital meeting room from which I called her back.

Looking out the window at the brick wall facing it, I heard her sobs on the other end of the phone. Before she could speak, I said, “Catherine, this is inappropriate. We should not be talking between sessions. We’ll talk about this on Wednesday.” There was shocked silence on the other end of the phone, and then more sobs. “We can talk on Wednesday,” I repeated.

I thought Kernberg would be proud of me, but I felt terrible inside. I’d abandoned Catherine, just as her mother had done so many times—showing up, appearing to be loving and supportive, and then disappearing again.

Catherine didn’t come in on Wednesday and didn’t want to discuss what had happened when I’d called. I didn’t see her again for almost 10 years. The peer supervision group members were congratulatory, but the idea that I’d done the right thing didn’t sit well with me. I knew I’d hurt Catherine, and hoped she was okay.

- - - -

By 1998, I was a licensed psychologist and trauma specialist. I’d trained with Judith Herman, and I’d been a supervisor and instructor at Bessel van der Kolk’s clinic for several years. At van der Kolk’s urging, I trained in eye movement desensitization and reprocessing (EMDR) and spent eight years honing my craft as a trauma therapist. Then, one day, to my shock and surprise, Catherine called me to see if she could make an appointment.

So often we’re advised not to apologize for our therapeutic errors because of risk-management concerns. I agree that apologizing to litigious, chronically devaluing clients is indeed risky, but I think we can always apologize for what I call mistakes of the heart—made out of a wish to help, out of well-meaning attempts to do what we’re advised to do, or because we care too much. It was a mistake of the heart to cut Catherine off suddenly and change therapeutic frameworks without explanation—on the phone, no less. Thinking I knew too little and believing my white, male colleagues with doctorates and MDs to know more, I did what they’d told me to do. Had I listened to myself, I would’ve found a more relational way to contain the phone calls and bring order to the treatment. I now know how to prevent long meetings outside of the therapy, but I didn’t back then.

Catherine received my apology with tears and gratitude. It meant so much to her to have me take back the pathologizing of her behavior and the abrupt rejection that had devastated her. She’d been wounded before, but had never experienced someone taking responsibility for hurting her and trying to repair the relationship. We both felt closer as a result, thanks to her courage in coming back to therapy with me.

Still prone to tears, she was more confident and centered in sessions this time. She and Abe had weathered the storm of his midlife crisis, and their children were doing well. The reason she was wanting to see me was that her mother had recently died, unexpectedly opening the floodgates to a tidal wave of traumatic, overwhelming memories.

It made sense now why Abe’s threat to leave had triggered her collapse. The traumatic memories bubbling up were all connected to her parents’ divorce and subsequent traumas, like being molested by one of her mother’s boyfriends, physical abuse by her father, and emotional abuse by her mother and grandmother. She’d come to me with the hope that she could regain her balance before more old traumas caused her to crumble.

In the 10 years since we’d last met, trauma treatment had changed, and with it, psychotherapy. Brain experts like Allan Schore and Dan Siegel had made neuroscience mainstream. Van der Kolk had introduced the concept that the body keeps the score. Now, Catherine and I could talk about her desperation to talk to me as a feeling memory of her childhood experience, when no one listened, understood, or took the time to make sure she was safe.

“Of course that desperation gets triggered when you’re flooded by these memories,” I told her. “That’s only natural. It’s part of the memory you must have felt many times.” I validated her experience again and again, but I did not offer, nor did she ask me, to be available by phone.

I did offer to do EMDR with her. We found she could easily access memories and tolerate the intense feelings that came up, once she discovered that they subsided if we just kept on going. Still, she got blocked when she tried to process certain emotionally painful pieces of her past. Other times, she’d suddenly lose connection to the feelings and memories and space out or go numb.

After seeing this pattern repeat session after session, we both felt certain that, deep down, Catherine had a fear of going any further, and it seemed pointless to keep pushing against the immovable block she kept encountering. At this point in my career, I wasn’t sure how to move us forward. This time, however, we said goodbye with mutual warmth and appreciation.

But apparently our work wasn’t over.

Earlier this year, I received an email from Catherine, asking if I’d see her again. The pandemic had triggered a frightening level of panic in her, and she was beginning to feel depressed.

"'I feel like I’m sitting on a dark secret,' she said, 'and I don’t know when the canister will ignite and overwhelm me.'"
PHOTO © ISTOCK/CHUNYIP WONG

With more than 40 years of practice since we first met and two books under my belt, I’m now an over-the-hill therapist, but one who’s still committed to exploring approaches to trauma that were unimaginable in 1998. I knew this time that Catherine and I could work with her body and nervous system, or we could work with my Fragmented Selves model, Trauma-Informed Stabilization Treatment (TIST). TIST is inspired by concepts from Sensorimotor Psychotherapy, Internal Family Systems, and Structural Dissociation, conceptualizing trauma survivors as inherently fragmented and self-alienated. The imperative to survive at all costs, especially when we’re young, depends on the mind’s ability to split, fragment, or dissociate, so that part of us can keep on keeping on, and part of us can remain vigilantly focused on the traumatic threat.

After hearing Catherine describe the struggles she’d been experiencing since the pandemic, I grasped the fragmentation that had always existed within her. I hadn’t seen it earlier because I hadn’t understood it myself back then. In the 1980s and 1990s, parts were an extreme symptom of dissociative identity disorder. As far as we knew back then, “normal” clients didn’t have parts.

By 2021, however, I’d become a parts whisperer, and I could hear the parts speak through Catherine. She described the panic she was feeling every morning, the separation anxiety that mounted when Abe would go out to the store or coffee shop. I was reminded of the 1989 Catherine, realizing I’d been treating her cry-for-help part then, the young part overwhelmed with separation anxiety. Starting with the assumption that every distressing thought, feeling, or physical reaction is a communication from a part, I asked Catherine to assume that her fear belonged to a part trying to tell her how scared she was. It took some practice for her to notice the fear as the panic of a child part, rather than her own feeling, but when she did, she immediately felt more curious about it than afraid.

“That part is mostly triggered by Abe,” she observed. “He wants to go down to the coffee shop and hang out with the guys. I can’t talk any sense into him.”

We observed the pattern that occurred almost daily: the child part would panic as Abe would get ready to go out, and then Catherine would lecture him about taking proper precautions, which Abe would brush off, further frightening the child part. I asked her if she could try to offer support to the young part, rather than letting her lecturer part try to control Abe.

“It’s okay. He’s always like this,” she told the part. “But he always comes home, and he always ends up being okay. He’ll come home, I promise.” She could feel the child part calm down a little, and then get fearful again until Catherine reassured herself once more. While the young part could only anticipate abandonment, Catherine realized that she herself had learned to trust Abe’s ability to land on his feet, but the young, frightened part had no way of knowing it without her reassurance.

Next, we addressed Catherine’s depression.

“I’m up half the night and wake up tired at 1 or 2 in the afternoon,” Catherine told me. “Then I fall asleep on the couch after lunch, and wake up again around 5 p.m., but I don’t feel like doing anything. I’m just too tired.”

I asked Catherine to assume that this was a tired part and to ask that part what it was worried about if Catherine didn’t nap.

Catherine paused, and closed her eyes. “She’s worried that it will be too much—that I’ll be overwhelmed.”

It made sense that a part of her would be afraid of being overwhelmed. After all, that was the predominant feeling Catherine recalled from childhood.

“This part is trying to protect you,” I responded. “She has no confidence that you can handle the overwhelm any more than you could as a child. She doesn’t know the strong woman you became.”

Catherine had inadvertently reinforced the part’s belief in her inability to cope by identifying with its fatigue and sleeping through most of the day. It took several weeks for her to learn to notice the tiredness as the part’s tiredness and not her own, and then to tuck that part into bed each morning and invite her to sleep while she went on with her day.

In just a few weeks, Catherine began to feel she had a life again. Without the tired part overwhelming her with fatigue anymore, she took up activities she’d dropped, and she’d developed a routine that was bringing structure to her day. “I can tell the part feels safer now that I’m in charge,” she observed—a contrast with the chaos of her mother’s and father’s homes.

Now, with each new challenge or symptom that arises, Catherine and I assume that it’s another part letting her know, “I need help, too.”

One week, a part emerged expressing terror connected to an image of a canister exploding. “I feel like I’m sitting on a dark secret,” she said, “and I don’t know when it will ignite and overwhelm me.” The feeling of not wanting to know, of something blocking her, was reminiscent of the EMDR treatment days, but this time, I could remind her that she and the parts had the power to decide if or when to open the canister.

“As long as the parts feel safe here with you now, the past can’t hurt you anymore. You can choose to know more, and you can choose not to know more. Ask the parts if any of them want you to open the canister. Is there any part that needs you to know what’s inside?”

In TIST, the goal is not to remember but to repair the wounds of the childhood past. Repair for Catherine’s parts meant respecting and caring for their feelings and opinions. Now, that’s what she offers them each day. While once they were invisible to the parent figures charged with their care, today they’re seen and heard with kindness.

- - - -

How far the world of mental health has come since 1987!

Parts-based approaches like IFS and TIST have become staples in trauma treatment. EMDR is now well-established as an evidence-based treatment, and we can talk about the body in psychotherapy without sounding “out there.” Trauma treatment has become a specialty area, with more and more therapists seeking the most up-to-date trainings. And importantly, we’ve learned to be flexible, using different approaches as needed on a client-by-client basis.

I couldn’t be flexible in 1987. Even senior therapists of that era didn’t know what we know today. We didn’t think of borderline personality as a trauma-related disorder. We didn’t know child abuse was an epidemic. We didn’t recognize the signs of trauma, and we didn’t know what to do with it, other than to ask victims to describe what had happened to them.

As I look back, I’m so grateful to Catherine for making this journey with me over all these years, bearing with me as I learned to understand trauma and trusting me to do the best I could, even when I wasn’t doing it very well.

As I often tell my trainees, “Everything I will teach you I’ve learned the hard way.”

Maybe the hard way is how we learn best.

***

Janina Fisher, PhD, is a licensed clinical psychologist and former instructor at Harvard Medical School, an international expert on the treatment of trauma, and the author of Healing the Fragmented Selves of Trauma Survivors: Overcoming Self-Alienation, Transforming the Living Legacy of Trauma: a Workbook for Survivors and Therapists, and her latest, The Living Legacy of Trauma Flip Chart: A Psychoeducational In-Session Tool for Clients and Therapists. Contact: janinafisher.com.

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PHOTO © ISTOCK/GEORGECLERK




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