Top 5 mistakes therapists make when treating clients with trauma
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.”