There is no greater agony than bearing an untold story inside you.
-Zora Neale Hurston
“What is trauma therapy, and what’s so different about working with trauma?”
When I teach this subject here at Manhattan Institute and elsewhere, these questions naturally arise. If I redirect the first part of the question back to the participants, a common response may go something like this: “You ask the patients to describe their traumatic experiences in detail, and then you process each element of those memories until their distress subsides.” This model, founded on the cognitive therapy approaches of systematic desensitization and exposure therapy, is widely taught and utilized. Through a combination of repeated exposures to traumatic memories, images, and sensations, paired with relaxation techniques, the memories and anxious and fearful responses to them may become desensitized or reconditioned.
This variety of treatment undoubtedly has pertinent applications and benefits, when for example attending to a single-incident trauma or simple phobia. It is my belief and experience, though, that these methods become increasingly insufficient when attempting to treat more complex and persistent forms of psychological trauma, especially where dissociation is prominent.
In the late 19th Century, psychoanalytic pioneers Janet, Freud and Breuer began connecting what were then called hysterical symptoms (extreme emotionality often accompanied by amnesias and somatic conditions) with early life traumas. Breuer and Freud stressed the importance of recognizing the clinical implications of “traumatic memories which have not been . . . associatively linked with other thoughts” (Howell and Itzkowitz, p. 23). Their associationist and abreaction models called for the need to link and symbolize traumatic memories within the stream of normal consciousness in order to bring about symptom reduction. Thus, contemporary trauma treatment originated in the first psychoanalytic theories and therapies (see Howell and Itzkowitz, pp. 20-32).
In 1992, Judith Herman, in her now classic book Trauma and Recovery, proposed a new diagnosis that she called Complex Post-Traumatic Stress Disorder (C-PTSD). Added to the then-existing diagnostic classification of PTSD were criteria such as “alterations in affect regulation, consciousness, self-perception, relations with others, and alterations in systems of meaning [emphasis added]” (p. 121). While in the ensuing 20-plus years some of these features have been lightly incorporated into the current DSM-5 criteria for PTSD (see pp. 271-280), broad acknowledgment of the essential distinctions between the bio-behaviorally-based changes seen in simple PTSD (alternations between intrusive reliving and emotional numbness) and the multifaceted psychological manifestations evident in C-PTSD has not yet gained full official recognition. Analogously, the treatment modality (an example of which I briefly noted above) remains central in conventional educational settings, whereas the core psychoanalytic discoveries and contemporary relational approach to working with trauma are underestimated.
According to Courtois and Ford (2009), “Complex psychological trauma represents extreme forms of traumatic stress due to their nature and timing. . . . [T]hese experiences are typically chronic rather than one-time or limited, and they severely compromise the individual’s personality development and basic trust in primary relationships”(p.14). Further, the traumatic events typically involve direct harm, neglect, abandonment, and betrayal by a needed caregiver at developmentally vulnerable times in the individual’s life. In another suggested designation, “Developmental Trauma Disorder,” the specific affective sequence of “rage, betrayal, fear, resignation, defeat and shame” is the singular subjective criterion for complex stress disorders in children (Van der Kolk, 2005).
Richard Chefetz, an expert in the relational treatment of persistent trauma-based dissociative conditions, comments on the effects of early relational trauma on self-development: “Traumatic experience . . . alters the developmental trajectory of an individual through changes in the organization or constitution of their self-states[emphasis added], the ability to have emotional experience . . . the capacity to live in relationship with self and others, and the maintenance of an enduring sense of self” (p.191).
Taken together, these glimpses into the world of someone suffering with C-PTSD (complex, cumulative, and chronic) underscore the need for a treatment that engages the whole person in an in-depth therapeutic endeavor; one that reaches well beyond the scope of more recently developed trauma processing models (e.g., EMDR and Somatic Experiencing).
Howell and Itzkowitz (2016) point out that the psychoanalytic trauma clinician may at times be required to take a more active approach such as using relaxation, grounding, or hypnotic techniques (pp.7-19). I agree. These established methodologies, along with the newer trauma resolution procedures, are indeed worthy therapeutic adjuncts and tools; however, they are not equivalents of or substitutes for comprehensive and specific training in the psychotherapy of relationally-mediated complex trauma. A tool is only as useful as the skill of the person who handles it.
In the post 9/11 era, we have become much more cognizant of the reality and pervasiveness of trauma—massive and catastrophic as well as private and individual. This heightened awareness is coincident with the rise of the above-mentioned trauma therapy models and of briefer, “evidence-based” psychotherapies, many of which proffer fast-tracked resolution of even very complicated clinical portraits.
This emphasis on swiftness, it seems to me, is antithetical to the very nature of traumatic encryption and recall. The splits, fissures, and dissociative gaps in awareness became structured into the mind of a traumatized person to serve a crucial function—as protective barriers against that which was intolerable, terrifying, cruel, and disorganizing. As associative (versus dissociative) processes ensue in treatment, the unsymbolized markers and sensations of overwhelming terror, helplessness, annihilation, dread, etc., shift—sometimes lurch—into conscious awareness. Any therapist who has witnessed this phenomenon knows that as the isolated, dissociated self-states and fragments of traumatic memory come into closer connection with the patient’s consciousness, a degree of traumatization often recurs. This is one crucial dynamic that makes working through traumatic adaptations such challenging and sensitive work. How could these detached aspects of self-experience possibly be rapidly modified or integrated without posing serious risk of destabilization?
To the extent that complex traumatic syndromes represent adaptations to actualchronic and often cumulative harm from the outside, externality delivers constant cues and reminders of past traumatization. As such, C-PTSD frequently includes a limited facility for coping with numerous aspects of reality—both inner and outer. The dampening effects of derealization and depersonalization are ubiquitous features of dissociative responses to trauma, as are, paradoxically, vehemently felt but clinically impenetrable emotions, beliefs, and physical sensations (Steinberg and Schnall, 2003; Van der Hart, Nijenhuis, and Steele, 2006).
The psychoanalytic trauma therapist must recognize and respect these and other constraints upon the trauma patient’s capacity for growth, change, and cohesive relatedness. The work should be judiciously and purposefully paced, always moving in alignment with the shared level of comfort, safety, and trust in the therapeutic dyad. The sometimes necessary and unavoidable micro-retraumatizations that signal the linking of previously dissociated elements must be curated to a manageable level of tolerance. Because familiarity—positively or negatively charged—is synonymous with a felt sense of safety for many survivors (novelty connotes danger), the anticipated struggle against internalization of new experiences also cannot be overlooked. The practical titration of traumatic material, within the context of a safe-enough therapeutic container, is how we help to build resilience and promote healing; and not, as is frequently held, by walking with the patient directly into their trauma vortex (Levine, 2010).
Trauma-specific psychotherapy training provides the clinician with an indispensable foundation for carrying out this demanding, enormously compelling, and rewarding work.
Sandra L. Green, LCSW, SEP is Executive Director, Faculty, and Clinical Consultant at the Certificate Program in Trauma Studies, Manhattan Institute for Psychoanalysis.
For information on the Certificate Program in Trauma Studies at the Manhattan Institute for Psychoanalysis, click here.
American Psychiatric Association (2013). Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition.
Chefetz, R. (2015). Intensive Psychotherapy for Persistent Dissociative Processes – The Fear of Feeling Real. W.W. Norton & Company.
Courtois, C. and Ford, J. Eds. (2009). Treating Complex Traumatic Stress Disorders.Guilford Pr.
Herman, J.L. (1992). Trauma and Recovery. Basic Books.
Howell, E. and Itzkowitz, S., Eds. (2016). The Dissociative Mind in Psychoanalysis–Understanding and Working with Trauma. Routledge: Relational Perspectives Series.
Levine, P. (2010). In an Unspoken Voice. North Atlantic Books.
Steinberg, M. and Schnall, M. (2001). The Stranger in the Mirror: Dissociation – The Hidden Epidemic. Quill Publ.
Van der Hart, O., Nijenhuis, E., and Steele, K. (2006). The Haunted Self – Structural Dissociation and the Treatment of Chronic Dissociation. W.W. Norton.
Van der Kolk, B.A. (2005). Developmental trauma disorder, Psychiatric Annals 35,401-408.