Over the past 10 years of my career, I’ve had the privilege of providing, training, and supervising clinicians and students in a myriad of therapies that treat the after-effects of trauma. I am passionate about trauma work because I feel such sympathy and drive to help people who, through no fault of their own, encountered and survived horrifying experiences. My favorite therapies are Dialectical Behavior Therapy (DBT) and Prolonged Exposure (PE) because my favorite clients to treat have co-morbid PTSD and Borderline Personality Disorder. It is an amazing and humbling experience to witness people who’ve been through so much get their lives back. Though with such intensive work, many therapists can feel overwhelmed or not sure if they’re doing the most helpful thing. Through my experiences, I’ve identified 5 common things that therapists often instinctively do that can derail therapy. Hopefully this information can help in your own practice treating clients with trauma histories.
1. Trying to convince the client that it wasn’t their fault
I cannot remember a single client I’ve worked with who did not believe that, to a large degree, the trauma was their fault. As a compassionate therapist, we so badly want to support and empower them to see that it wasn’t! But for the client, this belief creates a sense of control – if they believe they caused the trauma to happen, that means they can prevent something like that from happening again. The body would much rather feel (false) guilt over doing something wrong than the initially terrifying feeling that we live in an uncontrollable world, there was nothing they could have done to prevent it, and therefore, they need to accept the (realistic) probability of bad things happening in the future.
In our efforts to try to help, a common mistake is to try to convince the client that it wasn’t their fault, as opposed to staying open to any possibility and letting the client come to the realization on their own. Through effective processing of the trauma, the client will get there, but that sense of guilt is often the last to go. We need to tolerate our own distress of witnessing people feeling false guilt in order to help them get to a place where they truly believe they weren’t to blame. With Borderline PD clients who struggle with a sense of self and are constantly wondering what others think, I’ve found it helpful to share, “For the record, I in no way believe that this was your fault. I think you were a child who did what you could do to survive and there was no way you could have prevented your father from treating you that way. I also get that you do not at all believe this, and a big part of this therapy will be helping you to see that.” This allows you to share your opinion, gives them confidence of what you actually think, while also being open and supportive of them feeling differently.
2. Being too human/not human enough.
Without training in trauma, many therapists naturally go too far on one side or the other: being too sympathetic and engaged with the client or being too distant and impassive. On the overly sympathetic side, this can lead to therapist avoidance of talking about the trauma. It is hard to hear about horrific things and to see someone you care about in emotional distress. Or the therapist can tolerate hearing about it, but they care so much, they bring it home, resulting in therapist burnout. The flipside is trying to prevent this by being too impassive or stoic. Allowing the client to have any emotion or share any details without any human reaction. This can communicate to the client that their trauma “isn’t that bad” or they’re “overreacting.” The most effective level is in the middle. Channeling your own genuine reactions into what’s most effective for the client to heal – this is a balance of showing genuine compassion and reactions to validate their own experience and emotions, while also communicating that you can handle this. Many clients are afraid to share details of their traumas because they’re afraid of hurting their therapist! Be very careful that your level of disclosure does not communicate this to the client.
I view an effective therapeutic relationship as one where you are a person and are having genuine reactions, as long as those reactions are from a place of confidence and hope. When I’m present with a client, I think of myself as helping them “hold” their memories and emotions. Sometimes I imagine a large glass bowl between us that we’ve put the memories and emotions into, so that we can both back up and look at it and figure out what to do with it. I’m not taking it on for the client, and I give it back at the end of the session. I absolutely believe that they can handle this, and I’m here to help. In those moments, we are in it together. After the session, they hopefully have just a bit more awareness and skills to use to manage this week a bit better than the week before. The therapist needs to convey the message “I can totally handle this. And so can you.”
3. Treating clients fragily/equating feeling badly as bad, and feeling good as good
So often, therapists without formal training in treating trauma tend to be afraid of causing their clients to be distressed, or even “re-traumatized,” by talking about their past traumas. This is understandable because we’re therapists – we got into this field because we care about people and want them to be happy. So when clients start disclosing past traumas, newer therapists tend to want to soothe them and change the subject. This good intention can have the negative consequence of communicating to the client that they, or even you, can’t handle talking about the trauma, or that the solution when you’re upset is to avoid. This can be very detrimental to people with PTSD because PTSD is created and maintained by avoidance! One metaphor is thinking of trauma work as debriding a wound – it’s painful, but needed for healing to happen instead of dealing with the pain of it festering every day. If they have PTSD, they’re already thinking about it daily. Exposure work is talking about it in a way that would help. Also, remember, they survived the trauma itself! They can handle talking about it in your office.
4. Confusing ruminating with intrusive thoughts
With clients with PTSD, they do not want to talk about their trauma. Without exception. They may need to know they have to, they may initiate it, but they won’t want to and it will be very difficult for them to share details and/or express emotions initially. They often avoid eye contact, and you can tell, this is not what they want to be doing. Avoidance is the hallmark of PTSD.
In many people with a history of trauma, they develop more of an anxiety reaction as opposed to an avoidance reaction. This means that they are constantly ruminating about the trauma and really want to talk about it. It feels good for them to talk about it and “get it off their chest.” The problem is that good feeling only lasts as long as the session and they soon feel the need to “process” it again. If this is the case, it is not PTSD. The trauma happened, the distress is real, but they’ve developed an anxiety or depressive reaction in response to it, not PTSD.
Intrusive thoughts of PTSD come into the client’s head and they do all they can to block it out and avoid; Anxious/ruminative thoughts come into a client’s head and they keep it around: thinking, worrying about it, getting angry, sad, indignant, and they want to talk about it. Therefore, the treatment is different. If someone is already thinking about and ruminating on their traumatic past all the time, without trying to avoid or block it out, doing exposure work of talking about it more will actually make it worse and keep them stuck.
So, with rumination, you do the opposite of exposure work. Help them learn how to distract themselves, block the urges to talk about it (including in sessions), and learn how to focus on developing their values and other aspects of their lives. Help them make their lives about more than being a survivor of trauma.
5. Not using effective treatments or measures of progress
Trauma treatment is a highly specialized area of mental health. Exposure work needs to be done in a systematic way, in a shaping, stepped approach. Please, please do not attempt to provide trauma therapy such as Prolonged Exposure, Cognitive Processing Therapy, or EMDR, without sufficient training and consultation. If you don’t have specialized training, it’s extremely helpful to teach clients coping skills in order to prepare for trauma work, but then refer them to a trained provider for the formal trauma treatment. Teaching mindfulness skills is really helpful in the preparation stages, such as the methods taught in DBT, Acceptance and Commitment Therapy (ACT), or Mindfulness Based Stress Reduction (MBSR). Also, general coping skills of how to regulate emotions and stay grounded are excellent tools to have in preparing for trauma work.
It’s important to let the client know the range of treatments available out there so they can make an informed decision on what type of therapy is right for them. If they want to do the kind of therapy you offer, it’s important that you then agree upon what the goals would be, how you know if it’s working (or not), and how you’d know when therapy is completed. Many clinicians offer indefinite supportive therapy, which feels validating and comforting, but does not actually change emotions or coping styles long-term. I can’t tell you how many clients I’ve seen who had previously been in therapy for years without feeling much benefit beyond feeling supported and understood in the sessions. Certainly feeling supported and understood is important and critical! But it’s rarely sufficient to creating lasting change. So figure out how you can tell if your specific approach is working or not. I use the free DASS (Depression, Anxiety, and Stress Scale) to chart progress. There are many measures available out there. Asking them to complete a quick measure at least every 4th session will let you both know how things are going. If a client’s symptoms aren’t improving after about 3 months for general individual therapy or DBT, I talk to them about this approach maybe isn’t the best approach for them. Then we can collaboratively agree on a different approach, or I can refer them to someone who has a different approach than I do. In PE or CPT, a standard treatment length is 3 months, so I’m watching more closely and having that discussion earlier if they aren’t seeing improvement.
In summary, I believe that we are compassionate, dedicated providers who want to help our clients as much as possible. There are so many options out there; it can be daunting to decide which approach best matches your style, how to get quality training, and where to refer when a different approach may help your client more. All we can do is be open, informed, and critical thinkers, and consult. I hope these points from my experiences can be helpful for you!