Shades of Gray: When a therapist and her client are survivors of child abuse

Shades of Gray: When a therapist and her client are survivors of child abuse

by Lisa Cassidy
When are we far enough down the path of our own healing that we can safely go back and help someone else along? A therapist shares the story of confronting this urgent question with a traumatized client suffering from Dissociative Identity Disorder.

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Not a case to wow you with

This story is about humanness, grayness, and uncertainty in practicing psychotherapy. It's not about the times I've wowed a client with my perceptiveness and incisive interpretations. Neither will I focus on times when I've made a clear misstep, like mixing up two clients' stories. This is about intentionally making an imperfect decision to accept a college student as a client who was suffering from the effects of severe childhood sexual and physical abuse, while I at the same time was dealing with my own similar past. In the case I will present, it later became clear that Callie was living with significant dissociation and identity confusion.

My decision to work with her was based partly on the difficulty of finding a better alternative. But I can now say, in retrospect, that underlying this decision was my own difficulty in acknowledging the power of my past and the strength of my defenses. In the end, did I make the right decision? I must admit the results were mixed. Like a swirling mixture of white paint with distinct flecks of black, a picture emerges for me that now, from the distance of time, reads as gray.

I've seen many times over (on both sides of the couch) this insidious grayness seeping into therapeutic relationships. My first therapist took a position that suddenly put him in frequent contact with all my peers in my graduate program—the very people I had been talking to him about. His decisions and handling of the matter brought about multiple problems involving boundaries, trust and our alliance which were painful for me and ultimately interfered in our relationship and the work.

I, too, have found that in my current position, working at a counseling center in a small, rural university, unavoidable boundary questions pop up regularly.
Do I allow a client to join a student project I'm running at the university? Do I attempt to prevent a former client from later working as a graduate assistant at our center?
Do I allow a client to join a student project I'm running at the university? Do I attempt to prevent a former client from later working as a graduate assistant at our center? When I present to a class, will clients be in the audience? I imagine most therapists unwittingly find themselves in uncertain ethical waters from time to time and that guidelines for dealing with such matters offer no off-the-shelf solutions. Instead, they must be worked through taking into account the people involved and the risks and benefits of the available options.

In this article I will examine just one type of ethical dilemma, but one that any therapist with a traumatic past must face:
When are we far enough down the path of our own healing that we can safely go back and help someone else along?
When are we far enough down the path of our own healing that we can safely go back and help someone else along? To what extent are we actually in a better position to help our fellow survivors because we can relate to their pain and have a burning desire to help them? Or are we so familiar with the client's pain that it triggers our own pain and the ensuing defenses? Or is it a little of both, and if so, what then?

Tragic life story

Callie1 first became known to me through Ella, an experienced counselor I was supervising during her doctoral internship at our center. Callie was a plucky woman in her early twenties who was referred by one of her professors. His class was working on a project that had sexual abuse as its theme, and the professor sensed from Callie's reaction that it was raising some emotional issues for her. At first, Callie denied any emotional difficulty with the project. But this stoicism proved to be a thin veneer covering a deeply wounded individual. Her life story, as she related it over the course of one and a half years of treatment with Ella and me, was the most tragic I have heard.

Callie was bounced from caretaker to caretaker from the time she was six months old until she was eight years old. At four years old, she was repeatedly sexually abused by her mother's boyfriend, causing permanent damage to her uterus. The perpetrator went to jail. Her mother, who knew about the abuse and didn't prevent it, also abused her both physically and emotionally. Indeed, Callie recalled how on her fifth birthday her mother had taken away an unopened present she had bought for her because Callie had let child protective workers into the house. Callie recalled other punishments, such as being burned with cigarettes and being locked in a room for a week.

One of the most horrific abuses occurred after a teacher told her mother that Callie preferred to write with her left hand, but should be encouraged to use her right hand.
Her mother brought Callie outside and told her to hold her left hand behind the tire of their car while she drove over it, crushing the bones.
Her mother brought Callie outside and told her to hold her left hand behind the tire of their car while she drove over it, crushing the bones. Verbal abuse included her mother calling her vulgar names and telling her that she had never wanted Callie, and in fact hated her.

Callie was also abused by another of her mother's boyfriends. Over the years, he broke approximately eight of her bones. Once he dropped her head-first off a balcony. After the injuries, she was driven to far-away hospitals so that no one would suspect abuse.

In therapy with Ella, Callie reported that she experienced recurring depression with occasional suicidal thoughts. She had been cutting herself off and on for about seven years. Significantly, she also stated she felt different than others. This hint at identity problems would prove to be a huge understatement.

Introducing Stacie

Callie let Ella know that she trusted her, and opened up to her about these very painful past and present difficulties.

In her tenth session, Callie arrived in fancier clothes and, to Ella's surprise, referred to herself as "Stacie."
In her tenth session, Callie arrived in fancier clothes and, to Ella's surprise, referred to herself as "Stacie." Rather than question it, Ella decided to "go with it." Realizing this as an opportunity to understand a normally hidden part of Callie, Ella asked Stacie questions about herself. Stacie, she said, protects Callie. Stacie saw herself as different from Callie. For instance, Callie didn't like her live-in boyfriend, but Stacie did and worked to keep him around. Stacie showed up again the next session. She stated that she first appeared on the scene when Callie had been sexually abused at age four. In Stacie's mind, Stacie herself was never abused. In fact, she didn't even have the same mother or last name as Callie. Stacie asked Ella not to mention her existence to Callie because Callie would "freak" if she knew about her.

Ella agreed to this request, but disclosed in supervision that she was not sure if this was the right decision or not. We discussed Callie's ultimate need to know about Stacie, but decided not to push the issue at that time. We wanted to give Stacie a chance to express herself without fear of overwhelming Callie.

It was Callie who showed up for the following session. Although she talked of forgetfulness, she didn't see it as a real problem.
If she saw books around her apartment that she didn't recognize, she would simply think to herself, "I must have bought them."
If she saw books around her apartment that she didn't recognize, she would simply think to herself, "I must have bought them."

Ella's internship was coming to an end, and the termination with Callie was not a smooth one. Two months before Ella's departure, Callie called her in crisis. Walking to her off-campus apartment the night before, Callie had been raped by a stranger. For many subsequent weeks, Callie naturally felt terrified, and would sometimes even hide in her closet at night. Although she continued to present herself as Callie during these sessions, during one session she said she felt like a child, and during another she described feeling like she was in a dollhouse with others controlling her. Her depression and cutting behaviors increased, and she hinted at feeling suicidal. Ella spent the last sessions continuing to help Callie cope with the rape, and processing her sadness about friends graduating and their therapeutic relationship ending.

Unspeakable, unthinkable and unknowable

The decision about where Callie should be seen next for therapy was not taken lightly. Ella suggested the possibility that I take her on as my client. This option made sense for several reasons: I had supervised Ella over the previous six months, so I was familiar with the case; Callie did not have transportation, money or insurance, so a workable off-campus referral would have been difficult to arrange; and, with Callie's permission, I would be able to continue consulting with Ella while working with Callie. While a referral to another therapist in our center would normally be a possibility, our center only employs one other psychologist. Callie had expressed fear of the other psychologist because she looks similar to her mother. The reasons for me to see Callie were stacking up, but the idea made me anxious.

This is where my own past enters in. Like Callie, I was sexually abused as a young child on multiple occasions. For me, it was by my father. Here, the "un" words best describe my reaction: The terror was unspeakable. The sinking feeling I felt upon realizing that my own father was capable of hurting me in that way was unthinkable. In fact, the whole experience was unknowable. It was too much to take in, too much to remember. A severing process began taking place in my brain. I now believe I would actually forget the abuse between episodes. But when the circumstances that led to abuse would recur, I would remember. In my child mind I would plan how to keep myself safe. Unfortunately, my army of stuffed toys, oversized nightgown, and tucked-in pajama shirt were surprisingly poor defenses. This thing that was too much to know would happen again. By middle school, I feared I was becoming insane because I spent so much time out of my body and things felt unreal. For instance, I would be engaged with others at school and then suddenly feel as if my connection to both myself (my identity, body and past) and my surroundings had been severed. I felt more like a consciousness than a person. I would try to behave as normally as possible until the episode passed, but it was hard.

Today, I function well. I have come a long way through my own psychotherapy. In fact, it's easy to be lulled into a sense of having made it, having survived and moved on. Occasionally, something will trigger my memories, and my defenses will rush to the rescue, warping my sense of time, place, and self. It's hard to process information at those times, which I suppose is the point of dissociation. But that state is transient and I understand it. That said, I do sometimes wonder if what seems normal to me, like episodes of dissociation, may be more abnormal than I can appreciate.

At first, I declined to take on Callie as a client, but offered to meet with her temporarily while we worked out a more appropriate referral. Soon after termination with Ella, Callie cut herself deeply enough to require hospitalization. She did not remember making the cuts. I realized that, ideally, Callie should receive treatment from an agency that had emergency back-up and a specialist in Dissociative Identity Disorder (DID). I referred her to a crime victim's center in the nearest town that specializes in trauma treatment. However, I was surprised to find that the therapist assigned to Callie was less qualified to take her on than I was. In fact, I learned that no one at the agency had experience working with DID. Although the nearest city had appropriate referrals, it was an hour and a half away.

Soon after her release from the hospital, Callie cut herself again, and was again hospitalized. Like the last time, she did not remember making the cuts. As the only therapist currently connected with her, and with an obligation to manage our students' mental health crises, I continued seeing her for crisis management.

Entering the grayness

Over these sessions, I started gaining confidence in my ability to meet with Callie. I felt like my interventions were helpful. I revisited the idea of taking her on myself. I considered the facts: By default and necessity, I had already established a therapeutic alliance with Callie; I had an understanding of her past and current difficulties; I was knowledgeable about the psychological effects of childhood trauma; and I wanted to help her. I decided to take the plunge. I offered Callie regular psychotherapy sessions and she agreed. I looked into the possibility of consulting with a DID specialist for supervision over the phone and was able to set this up. I assured myself that if I ran into personal problems doing this work, I would process them with this DID supervisor or with my informal peer supervision group. I would like to announce that I opened up and worked through my past fully in this case, but in reality, I never found the courage to do this. Although I discussed my work with Callie, along with my less-private reactions toward her, I avoided anything that had to do with my own abuse. The anxiety that would get triggered when I contemplated bringing up my past felt insurmountable.

Callie was open and disclosing with me but also seemed a bit distant. I wondered if she was reacting to my own sense of uneasiness. I was aware of an internal sensation of steeling myself when she talked. I wanted to be receptive to her, but I could feel that I was also being self-protective. I was slightly unnatural with Callie, always trying to work against my instincts to defend myself.

Nonetheless, we were making progress.
At the suggestion of my supervisor, I began to talk to Callie about her alters.
At the suggestion of my supervisor, I began to talk to Callie about her alters. She was resistant, so I proceeded cautiously. She admitted that her boyfriend would tell her that she was other people sometimes. He told her that she would occasionally drink from a baby bottle. When he would report on her strange behaviors, she would cover her ears and start humming. She also disclosed that she stopped reading her journal because she would read things she didn't remember writing, such as entries about her mother, but from a younger perspective. At times, she would get fuzzy in session and dissociate. She would say that she did not feel she was fully in her body. We would stop and do grounding work.

One evening I received a crisis call from Callie. Her boyfriend told her she had just pulled a knife on him in a threatening manner. Despite her objections, I called an ambulance to pick her up so she could be evaluated at a hospital. She did not remember this incident either, and I suspected involvement of the alters. In fact, there was accumulating evidence that the alters were "out" quite a bit of the time.
 


A gift to the therapist from Stacie upon termination of therapy.
This painting depicts Callie and the alters in front of the house in which they live.

A turning point in our sessions came when, again at the suggestion of my supervisor, I asked Callie, "Is there a Stacie there?" She paused. She said that she would find things with the name Stacie around her apartment. Also, her foster mother had given her a red-haired doll named Stacy, and she had always liked that name. I explained she had presented herself as Stacie to Ella.

The next session, Callie showed up looking differently. She wore make-up, fancier clothes and smiled a lot. I asked if she was Callie. She said, "No, I'm Stacie." For the rest of the school year, until Callie graduated, I would see Stacie often. Stacie knew all about the others.

In all, Stacie told me about all 11 different parts or alters, including herself and Callie, ranging in age from 4 to 22
In all, Stacie told me about all 11 different parts or alters, including herself and Callie, ranging in age from 4 to 22 (Callie's age). In Stacie's mind, they all lived in a house where they each had their own room. In addition to Stacie, I also saw the four-year-old, Tracy, who missed her "mother" (actually, Callie's elderly relative who took care of her for several years). Jenna, who was sad, angry, and wanted to die, presented herself as well. Jenna called one day to tell me that her ribs hurt and she didn't understand why no one would take her to the hospital.

By the time of graduation, evidence of improvement came when Stacie started whispering things to Callie. Callie was apprehensive, but also intrigued at the prospect of getting in touch with another part of herself.

The silver lining

As we came to the end of the school year and were facing termination due to Callie's graduation, we talked about our relationship. She told me that she liked me and that I was one of only five people she trusted. However, she also disclosed her initial reactions to me that confirmed some of my fears.

She said that in our early sessions she felt I didn't like her because I tend to sit back in my chair and talk in the lower range of my natural voice.
She said that in our early sessions she felt I didn't like her because I tend to sit back in my chair and talk in the lower range of my natural voice. She initially reacted to this, she said, by not liking me either, so she wouldn't get hurt. Also, she said that she did not find me as warm and open as Ella. However, she reported that her feelings changed over time and she grew to like and trust me. Because this feedback was different than any of the feedback I've received over the years, I assume that I was, indeed, somehow different with Callie.

Those words were hard to hear, but they also gave me a great opportunity. Callie had some borderline tendencies, and not surprisingly, in her relationships with others, she tended to split. I pointed out that she seemed to put people into two camps: perfect people who she saw as her saviors, and others who she viewed as "all bad." She immediately accepted this observation, and added that saviors who fail her fall right down into the "all bad" category. I told her that I hoped that our relationship helped her to see that there's actually gray in the world. I had my imperfections, but she had found that she could still like me, trust me, and connect to me overall.

And so, out of the gray imperfect mismatching of a wounded therapist with a wounded client, came a lesson that I hope has staying power for Callie. Sometimes gray is what we get, and sometimes gray is enough.

I will never know if I made the right decision in accepting Callie as a client. Healing from early trauma is a process with no definite end point. I do know that the timing was not ideal. I had not fully appreciated the power of my past, and was too ashamed and avoidant to seek out more intensive supervision when I suspected it was interfering. Indeed, based on my experience in working with Callie, I have become even more convinced of the value for therapists who are survivors to explore their past in supervision when working with client survivors. When ready to do this, I believe he or she will be in a more powerful position to help his or her fellow survivors.

Perhaps most therapists are never fully trained or completely ready to work with such overwhelming stories of child abuse, but certainly getting extra support for myself would have eased the burden. Perhaps if I had disclosed to my supervisor my concerns about taking on Callie due to my own past, she could have helped me talk through the pros and cons and we could have made a decision together. If we decided that I should go ahead and work with Callie, which I suspect would have been the case, I would have felt supported and therefore more confident in my decision. I believe this would have made me more confident in sessions with Callie.

Mostly though, I simply needed to express to someone the emotional hurt I felt—for the both of us—when Callie talked about the abuse and her longing for a loving parent. Her therapy was emotionally difficult for me, as well as for her. With more support, I believe I could have been less self-protective and more open to her pain.

It's been a year since Callie graduated from college. She has contacted me sporadically over the course of the year. After graduating, she moved away to live and work in the post-academic world—a heroic but ultimately shaky endeavor. She had searched for a therapist in her new city, but no one would take her on due to liability concerns. At her new job, coworkers began telling her that she seemed like different people at different times. Her thoughts turned to suicide. She moved back to her college town and was taken in by a middle-aged couple who had helped her through her college years.

By coincidence, after not hearing from Callie in months, I ran into Stacie last week. Smiling and radiant, she gave me a big hug. Her hair color had changed since I last saw her; she had added a reddish hue. She said she had dyed it on impulse the night before. I thought of her beloved Stacy doll. I wondered what Callie would think of it.

Thunderclouds, weapons and armor

Gray is the color of thunderclouds, weapons, and armor. We often use the word gray to describe situations of uncertainty. A blending of black and white, it represents a mixture of good and bad, right and wrong, danger and safety. It's harder to take a stand on gray areas. It's often not clear if we should turn back or soldier on. Ironically, gray is also a red flag. It warns us that if we decide to soldier on, we must go forward with humility and support, things which could have helped me to face myself more fully as a person and as a therapist. Whereas the basic supervision and consultation I received was quite invaluable, I was often left adrift and rudderless without the support and resources that I wish I would have engaged.

Just as Callie struggled to understand the gray areas in life, so did I. Gray is not something we choose, but so often something we get anyway. Gray was what I gave to Callie. I hope it was enough.

In such moments of hope paired with self-doubt, I remind myself what I told Callie: Sometimes we must accept a level of disappointment in order to take in the positives. We are called to accept our limitations, and do what we can do, even with the messiness and inherent contradictions life offers us. On one hand, my own childhood trauma offered me a way to understand and connect to Callie and her house full of alters; on the other, it kept me from being fully present with myself and Callie.

Grayness is real, so running from it does little for those like Callie or for our own growth as therapists and human beings.
Grayness is real, so running from it does little for those like Callie or for our own growth as therapists and human beings. Perhaps in the meeting of my grayness with hers, some meaningful realness was forged that can sustain her in the roughest of times. Remembering that gray truth helps to sustain me, as well.

Notes

1 Names are changed to pseudonyms throughout the article, including the author.



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The author is a licensed clinical psychologist who works in a small university counseling center in a rural section of the United States. She requested that her name be changed to protect the confidentiality of the client and her own privacy.

CE credits: 1

Learning Objectives:

  • Recognize complex ethical and clinical dilemmas facing therapists with traumatic pasts when they take on clients with similar histories.
  • Describe some of the author?s personal reactions to working with a sexually abused client suffering from Dissociative Identity Disorder.
  • Explain potential benefits of clinical supervision and consultation for experienced/licensed psychotherapists.