Affect-Based and Relational Healing Approaches to Complex Trauma

Christine A. Courtois, Ph.D.Christine A. Courtois, Ph.D.Psychologist, Independent Practice Psychologist, Independent Practice

Washington, DCWashington, DCcacourtoisphd@aol.comcacourtoisphd@aol.com

www.drchriscourtois.comwww.drchriscourtois.com

Interpersonal Trauma:

“A break in the human lifeline”Robert Lifton

Self and interpersonal effects brought to treatment

Relational Healing for Relational/Interpersonal Injury

RICH relationship/Risking Connection

Trauma-oriented approach involving:Trauma-oriented approach involving: RespectRespect InformationInformation ConnectionConnection Hope Hope

(Saakvitne et al.)(Saakvitne et al.)

Interpersonal Neurobiology

--Right brain to right brain attunement: implicit factors--Development of new neuronal pathways:“neurons that fire together wire together”connection enables genetic expression--“Earned secure” attachment through relationship

Psychotherapy is a “shared journey of inescapable mutual influence” (Schultz-Ross, Goldman, & Gutheil, 1992)

Response to Trauma is Impacted by Objective and Subjective Factors (Wilson, 1989)

ObjectiveObjective details of the experience and how it happeneddetails of the experience and how it happened

SubjectiveSubjective the individual’s unique experience of the the individual’s unique experience of the

situation situation

Therapist must seek to understand the unique Therapist must seek to understand the unique circumstance and meaningcircumstance and meaning

Transference and countertransference...“traditionally refer to the reciprocal impact that the patient and the therapist have on each other during the course of psychotherapy. In the treatment of PTSD…, the transference process may be trauma-specific…and/or generic in nature, originating from pre-traumatic, life course development as well as from traumatic events.” (Wilson & Lindy, 1994)

therefore, transference/countertransference reactions can be compounded by trauma

Attachment Patterns Resulting from Interpersonal Trauma that Might Play Out in the Therapeutic Relationship*

SecureSecure Insecure: anxious-fearful (vigilant)Insecure: anxious-fearful (vigilant)

Dependent (“velcro”)Dependent (“velcro”) AvoidantAvoidant Self-defeatingSelf-defeating With borderline characteristicsWith borderline characteristics

{per the work of Bowlby, Ainsworth, Main and colleagues; Alexander & {per the work of Bowlby, Ainsworth, Main and colleagues; Alexander & Anderson (1994); DeZulueta (1993); and Liotti (1992,1993) applied to Anderson (1994); DeZulueta (1993); and Liotti (1992,1993) applied to PTSD/DD’s}PTSD/DD’s}

Attachment Patterns Resulting from Interpersonal Trauma that Might Play Out in the Therapeutic Relationship (con’t)

Insecure: Anxious-avoidant (dismissive)Insecure: Anxious-avoidant (dismissive) Counterdependent/self-sufficient (“teflon”)Counterdependent/self-sufficient (“teflon”) DetachedDetached Dissociated Dissociated (Barach, 1991)(Barach, 1991)

Insecure: Disorganized/disorientedInsecure: Disorganized/disoriented Avoidant, self-defeating, borderline highest likelihoodAvoidant, self-defeating, borderline highest likelihood Contradictory, approach/avoid; push-pull styleContradictory, approach/avoid; push-pull style Dissociated (Liotti, 1992; 1993)Dissociated (Liotti, 1992; 1993) By age 6, often involves a sub-style of By age 6, often involves a sub-style of

controlling/caretakingcontrolling/caretaking

Object Relations Defenses

Purpose:Purpose: To preserve the object, the self, To preserve the object, the self, and and the attachmentthe attachment

Primary defenses include:Primary defenses include: Idealizing/devaluingIdealizing/devaluing Splitting of self and objectSplitting of self and object Identifying with the aggressorIdentifying with the aggressor

(In Blizard & Bluhm, 1995, quoting the work of Masterson, 1976, (In Blizard & Bluhm, 1995, quoting the work of Masterson, 1976, 1981)1981)

PTSD/DD Defenses

Purpose:Purpose: To avoid experiencing trauma memories, To avoid experiencing trauma memories, responses and emotions (pain, overwhelming responses and emotions (pain, overwhelming emotions, and feelings of powerlessness).emotions, and feelings of powerlessness).

Involves ego splitting and/or creation of new ego Involves ego splitting and/or creation of new ego states (through splitting of consciousness and states (through splitting of consciousness and awareness via dissociation) to project and contain awareness via dissociation) to project and contain disavowed and unacceptable feelings, impulses, disavowed and unacceptable feelings, impulses, or objects.or objects.

The Three R’s: Reenactment, Repetition Compulsion, and Revictimization Abused individuals may play out what they “know” implicitly, giving Abused individuals may play out what they “know” implicitly, giving

clues to their historyclues to their history In relationships in generalIn relationships in general

intimateintimate parentingparenting workwork

In the therapeutic relationshipIn the therapeutic relationship transferencetransference enactments, reenactments, projective identificationenactments, reenactments, projective identification

May give somatic/behavioral/relational (vs. narrative) clues especially May give somatic/behavioral/relational (vs. narrative) clues especially in response to triggers or feelingsin response to triggers or feelings

NB: the therapist must beware of interpreting too literally or overinterpreting, NB: the therapist must beware of interpreting too literally or overinterpreting, especially when memories are unclearespecially when memories are unclear

The Therapy Relational Matrix

PosttraumaticPosttraumatic

Involving one or a combination of re-enactment, Involving one or a combination of re-enactment, re-experiencing, and re-victimization re-experiencing, and re-victimization phenomena and alterations between phenomena and alterations between numbing/denial and intrusion symptoms along numbing/denial and intrusion symptoms along with hyperarousal and startle responses. with hyperarousal and startle responses.

(Loewenstein, 1993)(Loewenstein, 1993)

The Therapy Relational Matrix

DissociativeDissociative

Involving such properties as absorption, heightened Involving such properties as absorption, heightened suggestibility, focused attention, and amnesia; suggestibility, focused attention, and amnesia; altered perceptions; and cognitive distortions altered perceptions; and cognitive distortions such as literalness and the tolerance and such as literalness and the tolerance and rationalization of illogic and contradiction rationalization of illogic and contradiction (trance logic).(trance logic).

(Loewenstein, 1993)(Loewenstein, 1993)

Relationship with the Patient transference/countertransferencetransference/countertransference therapeutic alliancetherapeutic alliance real relationshipreal relationshipNon-countertransference (but may be affected by Non-countertransference (but may be affected by

countertransference):countertransference): positive attitude positive attitude warm, connected stancewarm, connected stance responsive/interactiveresponsive/interactive compassionatecompassionate empathicempathic appropriate and empathic confrontationappropriate and empathic confrontation interpretation interpretation

(adapted from Turkus, 1993)(adapted from Turkus, 1993)

The Therapeutic Relationship

Need for empathyNeed for empathy Need for attunementNeed for attunement Misattunement is an opportunity for repairMisattunement is an opportunity for repair

When ruptures occur (as they always will), the therapist uses the opportunity for communication and problem-solving leading to repair owns mistakes shares feelings in the moment (with discretion) is not blaming seeks to understand, collaborate

Therapist must not make self the “all-knowing authority on high”

Boundary Issues

Potential for boundary violations (vs. crossings) common with this population (indiscretions, transgressions, and abuse) Playing out of attachment style and issues Playing out the roles of the Karpman triangle, plus

victim, victimizer, rescuer, passive bystander potential for sado-masochistic relationship to

develop Roles shift rapidly, especially with dissociative patients Must try to stay steady state

Boundary Issues

Therapist must be aware of “treatment traps”, transference, countertransference issues and carefully monitor the relational process

Therapeutic errors and lapses will occur and how they are handled can either be disastrous or can be restorative to the patient and the relationship knowing about them can help the therapist get out of

them more rapidly and manage them with less anxiety (Chu, 1988)

Boundary Issues

Safety of the therapeutic relationship is essential to the work Responsibility of therapist to

Maintain vigilance and the integrity of frame Be thoughtful as to setting boundaries/limits

re: availability, personal disclosure, touch, fees, gifts, tolerance for acting out behavior, social contact, etc.

On average, start with tighter boundaries Avoid dual roles wherever possible Be prepared to hold to boundaries/limits but also to have some

flexibility Complete personal therapy as necessary Engage in ongoing continuing education,

consultation/supervision, peer support

Boundary Issues

Rescuing-revictimization “syndrome” “vicarious indulgence” as a treatment trap, especially for novice

therapists and those who have a strong need to caretake or are enticed by the patient

may give patient permission to overstep boundaries, ask for and expect too much

may then lead to resentment/rage on the part of the therapist and abrupt, hostile termination for which the patient is blamed

may relate to malpractice suits, in some cases (see BPD literature) Progression of boundary violations: the “slippery slope”

e.g., from excessive disclosure to patient as confidante, excessive touch to sexual comforting and contact

It is never OK to sexualize the relationship

Transference Reactions

Transference reactions, projective identification, and enactments are all ways that the traumatized, dissociative patient might communicate with the therapist who must strive to be open to experiencing them, identifying them, and seeking to understand their meaning with the patient.

Five Selected Transference Themes in Trauma Treatment

1. Traumatic1. Traumatic

2. Shame-Based2. Shame-Based

3. Merger-Abandonment3. Merger-Abandonment

4. Sadomasochistic4. Sadomasochistic

5. Loss-Based5. Loss-Based

Some Traumatic Transference Reactions

May be very confusing; shifting and alternatingMay be very confusing; shifting and alternating kaleidoscopic kaleidoscopic (Davies & Frawley, 1994)(Davies & Frawley, 1994)

Reenactment of Karpman Drama Triangle PlusReenactment of Karpman Drama Triangle Plus shifting roles of persecutor, victim, rescuershifting roles of persecutor, victim, rescuer additional role of passive bystanderadditional role of passive bystander

Projection of abuser role on the therapistProjection of abuser role on the therapist ““You will be like my abuser”You will be like my abuser” ““You will use me for YOUR purposes”You will use me for YOUR purposes” ““You will be gratified by my pain”You will be gratified by my pain” ““You are venal and self-serving”You are venal and self-serving” ““You too will betray me, are not to be trusted, ever!”You too will betray me, are not to be trusted, ever!”

VictimizerVictimizer

VictimVictim Rescuer Rescuer

Passive BystanderPassive Bystander

Traumatic Transference Reactions

Fear of being known & fear of being re-abusedFear of being known & fear of being re-abused Therapy may feel like torture to the patient due to control Therapy may feel like torture to the patient due to control

and power dynamicsand power dynamics patient is “intruded upon” and made vulnerablepatient is “intruded upon” and made vulnerable

Patient may behave like a victim and “invite” the role of Patient may behave like a victim and “invite” the role of perpetrator/intruderperpetrator/intruder

As compensation, perfection may be expected of As compensation, perfection may be expected of the therapist--anything less is intolerablethe therapist--anything less is intolerable ““You must be perfect, or you are like them”You must be perfect, or you are like them” ““You must take of me, love me, etc, You must take of me, love me, etc, perfectlyperfectly””

Traumatic Transference Reactions Erotic/eroticized transference may developErotic/eroticized transference may develop

Patient may resist or try to control/protect self through Patient may resist or try to control/protect self through dependence/attachment/seductiondependence/attachment/seduction

Erotic TransferenceErotic Transference: : Pertaining to the need to be special, Pertaining to the need to be special, exceeding the usual boundaries of treatmentexceeding the usual boundaries of treatment

Erotized TransferenceErotized Transference: : “an intense vivid, irrational , erotic “an intense vivid, irrational , erotic preoccupation with the analyst characterized by overt, seemingly preoccupation with the analyst characterized by overt, seemingly ego-syntonic demands for love and sexual fulfillment from the ego-syntonic demands for love and sexual fulfillment from the analyst”. analyst”. (Blum, 1973)(Blum, 1973)

Erotic and traumatic/dissociativeErotic and traumatic/dissociative transferences may cause transferences may cause the development of a sadomasochistic aspect to the therapy the development of a sadomasochistic aspect to the therapy relationship relationship (Chefetz, 1991)(Chefetz, 1991)

Traumatic Transference Reactions PatientPatient may victimize/“torture” the therapistmay victimize/“torture” the therapist

Direct action: assault, threats, property destruction, self-harm, Direct action: assault, threats, property destruction, self-harm, suicidality, risk-taking, stalking, intrusion into the therapist’s lifesuicidality, risk-taking, stalking, intrusion into the therapist’s life ““I’ll show you what it feels like”I’ll show you what it feels like”

Restitution and entitlement dymanicsRestitution and entitlement dymanics “ “You owe me and must make up for the past”You owe me and must make up for the past” ““You are not good enough/nothing you do is good enough”You are not good enough/nothing you do is good enough”

Malignant passivity and regressionMalignant passivity and regression “ “rescue me!”rescue me!”

Resistance and non-cooperation with treatment contractResistance and non-cooperation with treatment contract ““I’ll prove to you how bad I am and make you give up on I’ll prove to you how bad I am and make you give up on

me”me”

Some Shame-Based Transference Reactions Personal devaluationPersonal devaluation

““I am bad”I am bad” ““Don’t notice me”Don’t notice me” ““I deserve mistreatment and neglect”I deserve mistreatment and neglect” ““I’m unworthy and flawed, you’re not”I’m unworthy and flawed, you’re not” ““To work with me, you risk being like me”To work with me, you risk being like me” ““I’ll contaminate you”I’ll contaminate you”

Grandiosity as a defense Grandiosity as a defense ““I’m better than you and don’t need/want anything”I’m better than you and don’t need/want anything” ““Don’t see me for who I really am”Don’t see me for who I really am” ““I won’t let you in”I won’t let you in”

Merger-Abandonment Transference Reactions BPD-type dynamicsBPD-type dynamics

Preoccupation with regulating spacePreoccupation with regulating space Relationships are viewed as rigid, non-elasticRelationships are viewed as rigid, non-elastic Attachment to defend against fear of abandonment: Attachment to defend against fear of abandonment:

fusing/losingfusing/losing Attachment/rejectionAttachment/rejection Longing/dreadLonging/dread Connect/disconnectConnect/disconnect Idealization/devaluationIdealization/devaluation SplittingSplitting

Merger-Abandonment Transference Reactions Transference bondage Transference bondage (Kohut)(Kohut)

Patient trades autonomy for safety/attachmentPatient trades autonomy for safety/attachment Reparenting dynamicReparenting dynamic Dependence/passivityDependence/passivity

Idealization/devaluationIdealization/devaluation ““You are my savior/you are no good”You are my savior/you are no good”

Other-directness/superficial complianceOther-directness/superficial compliance ““What is it that What is it that youyou want?” want?” ““Let me take care of you because that is what I know/that is Let me take care of you because that is what I know/that is

how I stay safe”how I stay safe”

Sado-Masochistic Transference Reactions Power and control dynamicsPower and control dynamics

often to defend against terror, pain, and sadnessoften to defend against terror, pain, and sadness attachment/detachment through controlling or being attachment/detachment through controlling or being

controlledcontrolled

Victim/victimizer role enactmentsVictim/victimizer role enactments identification with the perpetratoridentification with the perpetrator revictimization and repetitions/reenactmentsrevictimization and repetitions/reenactments

Rage and pain to violence/sexualized violenceRage and pain to violence/sexualized violence Therapist as sadist or masochistTherapist as sadist or masochist

May be abuser, bystander, rescuer, or victimMay be abuser, bystander, rescuer, or victim

Loss-Based Transference Reactions Patient often has multiple losses to grievePatient often has multiple losses to grieve

Of self, lifetime, personal developmentOf self, lifetime, personal development Exploitation and betrayalExploitation and betrayal Lack of protection, neglect, abandonmentLack of protection, neglect, abandonment Reenactments and other behaviors/reactionsReenactments and other behaviors/reactions

Losses may be deniedLosses may be denied Anger may mask griefAnger may mask grief Patient may defend against the painful affects associated with losses Patient may defend against the painful affects associated with losses

and resist attempts to work with themand resist attempts to work with them Abandonment may be expected/feared Abandonment may be expected/feared

patient may expect no empathy and abandonment if losses are patient may expect no empathy and abandonment if losses are acknowledgedacknowledged

Losses may continue in the present, sometimes due to the Losses may continue in the present, sometimes due to the effectiveness of treatmenteffectiveness of treatment

Countertransference

Always present, so expect it!!!Always present, so expect it!!! Consider it a valuable source of informationConsider it a valuable source of information

Seek to talk about itSeek to talk about it Seek to explore and understand itSeek to explore and understand it

alone, in consultation and supervisionalone, in consultation and supervision with the patientwith the patient

When caught in enactments, try to use them to understand When caught in enactments, try to use them to understand the patient. Maintain therapeutic boundaries!!! Be aware the patient. Maintain therapeutic boundaries!!! Be aware of personal limitations and vulnerabilities. Seek of personal limitations and vulnerabilities. Seek consultation as neededconsultation as needed

Factors That Interact to Determine Countertransference

The nature of stressor in the event and The nature of stressor in the event and recountingrecounting

Personal factors in the therapistPersonal factors in the therapist Patient factors relevant to understanding Patient factors relevant to understanding

countertransferencecountertransference Institutional/organizational/societal factorsInstitutional/organizational/societal factors

Countertransference Indicators

Physiological and physical reactionsPhysiological and physical reactions Emotional reactionsEmotional reactions Psychological reactionsPsychological reactions Signs and symptoms that may be conscious or unconscious:Signs and symptoms that may be conscious or unconscious:

forgetting, attention lapsesforgetting, attention lapses loss of empathyloss of empathy anger, hostilityanger, hostility relief when appointment is missedrelief when appointment is missed denial of feelings or need for consultation denial of feelings or need for consultation excessive concernexcessive concern psychic numbingpsychic numbing self-medicationself-medication lossloss of boundariesof boundaries (Wilson & Lindy, 1994)(Wilson & Lindy, 1994)

Common Countertransference Reactions in Trauma Treatment Fascination, overinvolvement Disbelief, denial, underinvolvement Horror, disgust, fear Shame, guilt Anger, rage, irritation Sadness, sorrow, grief Powerlessness, overwhelmed, exhausted Incompetence, de-skilled, confusion Sexualization, voyeurism, exploitation, sadomasochism Difficulty with boundaries and limits

Countertransference Categories in Trauma Treatment

Type I: Avoidance, detachmentType I: Avoidance, detachment empathic withdrawal/empathic repressionempathic withdrawal/empathic repression

Type II: Attraction, overidentificationType II: Attraction, overidentification empathic disequilibrium/empathic enmeshmentempathic disequilibrium/empathic enmeshment

Type III: Aggression, hatred, exploitationType III: Aggression, hatred, exploitation absence of empathyabsence of empathy