There are ways in which our own trauma injuries can interact with therapy tools or the personality of our therapist that may create difficult or harmful situations for us. Therapists don’t always expect it because non-traumatized patients don’t struggle with these patterns and they might not be aware that we do. We will look at a couple of topics that could be tricky to navigate for both sides and what would be helpful.
Control over the treatment plan
Every therapist should make a treatment plan. It is a written document that describes our current situation and symptoms, our resources, competences and goals and how the therapist plans to approach the issues. It won’t be a perfect plan but it serves as a guide to keep therapy on track. Therapists who don’t know how to do this for DID find a guide in ‘Treating trauma-related dissociation’ (Boon, Steele, van der Hart).
The vast majority of patients do not even know that a treatment plan exists. They were not properly included in the making of it. In extreme cases, the therapist decides what the goal of therapy is (usually something like symptom reduction, simply because it is obvious, not because they asked). We as trauma patients need more active engagement in the formulation of our treatment plan. We need well-informed consent when it comes to our therapy goals and the tools that will be used. Otherwise we might drift into submission, appeasement or passivity. Therapy is done to us. Someone else decides our path. That is the opposite of agency. It does take more time to speak through a treatment plan in detail but the reward is that we as patients can be more actively invested and motivated and we are less confused or scared of something being done to us against our will. We become part of our own therapy instead of having it happen to us. Both we and our therapist agree on a map to follow. Every step of the journey that does not have our informed consent is creating a problem where we need blind faith in our therapists and risk getting hurt when a therapist misses something because we didn’t talk about it. Blind faith is not exactly a characteristic most trauma patients bring to the therapy space. And it shouldn’t be.
Proper cooperation keeps both sides safe. We as patients still need the expertise and guidance therapists offer; we can’t write our own treatment plan alone. But empowerment to contribute to our treatment plan is therapeutic. In the process, we don’t just strengthen the therapeutic alliance, we also learn that we have to play an active role in our recovery. It is valuable to do this work and invest the time in it. A therapist should never be in the role of deciding our path for us. The power imbalance turns that into something abusive. Our free will play a key role in our recovery.
Symptom reduction
Reducing symptoms is a classic goal in therapy. But it is not easily achieved in trauma therapy. We as patients might feel the pressure of having to reduce our symptoms, but we can’t, and then we may slip into an old submissive pattern and make them invisible. The experiences are still happening. We just hide them to make it look like they went away. That creates silent suffering and obstacles for honest conversations. Hiding is a natural response we as patients have when we can’t live up to the task in real life. That is not our fault. Sometimes therapists insist that patients sign agreements that they won’t have specific symptoms anymore, like self-harm or dissociation. These contracts work well for the peace of mind of the therapist who feels more safe knowing we promised not to do the big stuff. It rarely does something helpful for us as patients. A contract like this is an open invitation to suppress instead of successfully resolve symptoms. Sometimes whole treatment concepts are based on suppression instead of actually helping. Dissociative patients are masters of suppression. It doesn’t last and we will still face the same issues later.
The goal cannot be called symptom reduction if there is already a pattern of symptom suppression and masking problems. That would be the end of our progress. I personally prefer the term symptom management. It manages the expectation during the stabilization phase. We probably won’t be able to reduce a lot of our symptoms until after trauma processing. Until we can get the triggers out of the way we are focussing on managing what is happening and getting really good at that. It is not realistic to reduce the quantity of our trauma symptoms significantly before trauma work but they can become so well-managed that the quality of distress and suffering is reduced. Reduction of suffering is a better goal than symptom reduction.
Therapists must be extremely careful not to put the kind of pressure on us that would trigger our masking behavior. Signs that there is no space for our problems in therapy will lead to withdrawal. Once we become unable to share our real pain, thoughts or feelings because we expect that we get punished, controlled or avoided for having them, our therapy is doomed. There needs to be space for being real and space for struggling with symptoms. Even when that feels uncomfortable to therapists. Actually reducing symptoms is hard work on both sides. It is not done by telling us what symptoms we are supposed to control next. That can be very close to what abusers did to control our behavior to make it work for them. We can notice our own impulses to mask symptoms, and if it is impossible to address them in therapy we might want to change therapists. Applying ever more control is not real symptom reduction. Therapists can help us by being transparent about their expectations concerning the tools that they teach us. Even just knowing that this tool might not work or does not work for a certain percentage of patients can offer us the freedom to admit that something is not really working for us. A regular open conversation on what works and what doesn’t work introduces the permission to say that things don’t work. We might not know that we are allowed to say that, if we are not asked with the expectation that it is normal for some things not to work. The tendency to obey and meet expecations can be tamed by communicating different expectations.
(Note: There are many situations where masking symptoms is healthy and appropriate. Not every space in our life is safe for being symptomatic. Therapy should be a safe space, though.)
Exposure
Working through trauma memories can become a shared extreme experience between us and our therapists. Intensive treatment programs, hard confrontation techniques and strong abreactions can create a trance-like world of survival that we share with our therapists. As a response, we might slip into trauma bonding with them. The high level of suffering combined with the feelings that things have to be this way and there is a person who is very close to us in all of this and they act supportive most of the time is a recipe for trauma bonding. We might notice an excitement before trauma work that feels more feverish than anxious and maybe even slightly euphoric. Maybe we notice that the only time we actually feel deeply connected to our therapists is when we face really bad memories together and it motivates us to look at the worst things we can find inside.
The trance-like state can include our therapists, who might join us in our feverish trauma-seeking behavior where they get caught up in more and more intense and painful confrontations. Therapists might experience a pleasure of working with harsh exposure tools because of their faith that they help best, missing the point that the client is getting harmed or retraumatized in the process. It can turn into a loss of intuition and sensitivity for the needs of the patient and a rush of excitement when things hurt. This is the dynamic that can turn well-meaning trauma therapists into hard and merciless confrontation experts. And we as patients might feel attached to them through trauma bonding and follow their lead in good faith that they know best. Years after the attachment relationship ended we might look back at what happened with horror because we were not just unable to say no, we were highly invested in the dynamic. The therapist ended up in an abusive role and it all happened within the regular frame of how trauma therapy should work.
Therapists must carefully examine the motivation for trauma processing, their own and that of the patient. We as patients do well when we don’t do a lot of trauma processing in a very short period of time and insist on more gentle treatment options if they are available and more pacing if they are not. Gentle trauma tools also keep our therapists a bit safer from desensitizing themselves to the point where they lose important abilities of empathy. Intensive treatment programs that create a whirlwind of daily exposure are not appropriate for us. Trauma processing can feel personal, sometimes weirdly medical, difficult, scary, heart-breaking, freeing, but it must not feel like something that we survive alongside our therapists. I have good experience with treating trauma processing as an annoying necessity that I prefer to get through with someone I trust. No shared rush of excitement. As little intensity as possible while still actually getting to the core of the trauma. Trauma bonding enables mistreatment that feels like connection for both sides while it is happening. Please be very careful and aware of this potential dynamic. It is one of the most harmful ones I know.
Leaving the mixed bag behind
There is a tendency to stay in situations that feel like a mixed bag. Some of it feels helpful and we want to keep what is good. But some of it feels harmful and we are at least aware of our doubt in what is happening because our instincts tell us that something is wrong. We often stay because we focus on the good and we don’t see other options to get something good. I want to encourage you to listen to your doubt when you feel it. You do have a gut feeling about the things that go wrong. I can’t think of a positive thing in therapy that is worth getting harmed in other ways. Therapy should not harm. It sometimes does by accident and that is tragic. But it shouldn’t be the treatment approach itself that does things to us that increase suffering or trauma. You are allowed to leave. It is possible to find something better than that.
[This article is based on personal experience, observations while being a patient in different clinics and reports from other survivors]