Helping Clients to Understand and Overcome Traumatic Reenactment

As a psychotherapist who has specialized in working with trauma victims for almost 40 years, I have experienced many clients who are suffering from traumatic reenactments—the phenomena that occurs when people expose themselves to situations reminiscent of an original trauma, placing themselves at emotional risk or in physical danger in a compulsive mimicking of the past. For example, a woman who was physically abused by her father may continually find herself being attracted to abusive men. A man whose mother emotionally abused him may continually become attracted to women who are overly critical toward him. Yet when I attempt to help these clients make the all-important connection between these current reenactments and past trauma I’m often faced with reactions like, “but I didn’t experience any trauma growing up” or “I’ve already dealt with my past abuse, it’s not still affecting me.” Clients tend to minimize, deny, or “forget” their past trauma experiences.

Why Do People Reenact Trauma?

While reenactments are experienced by many people, those who were traumatized as children (including neglect, abandonment, and abuse) have a tendency to re-enact or relive past trauma more than the average person. Other types of traumas can also create the need to repeat what happened to us as a way of understanding it and bringing closure. This includes acts of nature such as floods, earthquakes, and tornadoes; the death of a loved one; as well as fatal accidents. Several theories have been suggested to explain the phenomenon of traumatic reenactments.

  • Many experts understand reenactments as an attempt to achieving mastery. This means that a traumatized individual reenacts a trauma in order to remember, assimilate, integrate, understand, and heal from the traumatic experience. (1)
  • Some experts perceive reenactments as spontaneous behavioral repetitions of past traumatic events that have never been verbalized or even remembered. For example, Freud noted that individuals who do not remember past traumatic events are “obliged to repeat the repressed material as a contemporary experience instead of … remembering it as something belonging in the past.” (2)
  • Others suggest that reenactments result from the psychological vulnerabilities characteristic of trauma survivors. For example, as a result of a range of ego deficits and poor coping strategies, trauma survivors can become easy prey for victimizers. (3)

Ongoing reenactments usually indicate that a former victim is emotionally stuck and can be interpreted as a “call for help.” They are attempting to work through some aspect of past trauma by repeating it with another person, hoping that this time the result will be different.

We don’t consciously and deliberately set out to repeat a parent’s behavior, get involved with a replica of an abusive or neglectful caregiver, or repeat a trauma over and over. These are unconscious actions on our part. Sigmund Freud stated that such unconscious processes may affect a person’s behavior even though he or she cannot report on them. For example, Freud and his followers believed that dreams and slips of the tongue were really concealed examples of unconscious content too threatening to be confronted directly. Reenactments can be seen as this type of unconscious behavior.

In addition to Freud’s concept of reenactments being a need to repeat the past in order to get a different result, I would add that reenactments are often an unconscious need for people to understand what happened to them and why. Those who are caught up in reenactments are often troubled (consciously and unconsciously) by events that occurred in their past. Some are confused about why people treated them the way they did. Others blame themselves. Still others are in denial about these events. They are overwhelmed by emotions such as shame, anger, fear, and pain, emotions that are often suppressed or repressed. All this confusion and denial work together on an unconscious level, causing them to reenact troubling events in an effort to gain understanding and closure. For example, a girl whose father abandoned her will likely be preoccupied with discovering why he did so and may blame herself in some way. As an adult, this will likely affect her relationships with men, causing her to both doubt her ability to keep a man interested in her and to be attracted to unavailable men.

Reenactments often lead to re-victimization and with it, related feelings of shame, helplessness, and hopelessness. For example, it has been found that women who were sexually abused as children are more likely to be sexually or physically abused in their marriages. Therefore, gaining an understanding and control of reenactments is a primary way to avoid further re-victimization and shaming.

The Reasons Why Clients Deny Having Been Abused

Even though they may suffer from reenactments, some people insist they have not suffered from trauma or are not sure whether they have or not. The reasons for this are many.

Denial and Minimization

Many people don’t label their experiences as traumatic, even when they are. Others minimize the damage an event or series of events had on them. In fact, the majority of trauma victims tend to deny or minimize traumatic experiences. As humans, we will do almost anything to avoid facing the feelings surrounding being traumatized, feelings such as fear, pain, shame, and anger. One of the best ways to avoid such emotions is to deny that the trauma ever happened. For example, even if a client is able to admit to himself that he was physically abused by his father, he may still be in denial about various aspects of the abuse. He may have convinced himself that “it wasn’t all that bad,” (minimization) or that his father didn’t mean to harm him (rationalization). In the case of a client having been sexually abused they may have even convinced themselves that it wasn’t actually abuse because they enjoyed it or because they believe they were the one who initiated it (denial).

Denial is a powerful, unconscious defense mechanism intended to protect us from having to face intense pain and trauma. It can even allow us to block out or “forget” intense pain caused by emotional or physical trauma such as childhood abuse. The denial process is designed to prevent us from facing things that are too painful to face at the time. But it also defends us against the truth and can continue way past the time when it served a positive function.

Former victims of child abuse often deny that they were abused, deny that it caused them any harm, and deny that they need help. The following are the most common reasons why victims of child abuse tend to deny what happened to them and/or minimize the damage it caused them:

  • They don’t want to feel the pain, fear, betrayal, and shame that acknowledging the abuse would cause them to feel. The abuse is either walled off from conscious awareness and memory, so that it did not really happen; or it is minimized, rationalized, and excused, so that whatever did happen was not really abuse. Unable to escape or alter the unbearable reality that they were abused, some children alter it in their mind.
  • They don’t want to admit that they were a helpless victim. It can be humiliating and degrading to acknowledge that another person can overpower you or have control over you. Instead of admitting either of these two things, victims often prefer to take responsibility for the abuse. This is especially true of male victims since males are raised to be tough and strong and to always defend themselves.
  • They don’t want to admit that someone they cared about could harm them and cause them damage. For those who were abused by a family member, a close friend of the family, or an authority figure they respected such as a priest, a teacher, or a coach, to face the fact that they were abused is to experience the sometimes unbearable pain of admitting that someone they respected or loved could treat them in such horrendous ways. The most common way for children to explain behavior on an abuser’s part, especially if it is someone they respect or love, is for them to blame themselves.
  • Another reason some former victims deny that they were ever abused is that they repeated the cycle of abuse by abusing other children. In this situation they may have an investment in believing that parents have a right to discipline their children, even if it causes physical harm. Those who were sexually abused often convince themselves that children are never really “forced or manipulated” into sex with an adult or older child, but they do so willingly and that they get pleasure from doing it. This kind of denial not only keeps former victims from admitting that they themselves were abused but that they became abusive.

Repression vs Suppression

Repression (unconsciously blocking out traumatic events) and suppression (consciously choosing to “forget” traumatic events) are survival skills that help former victims of trauma to move on with their lives instead of being so completely overwhelmed with feelings of fear, shame, or guilt that they can’t function. Unfortunately, these defense mechanisms can make it difficult for clients to allow themselves to remember and process a trauma.

Painful feelings and memories can be very upsetting. Instead of facing them, clients often unconsciously hide them from themselves in hopes of forgetting about them. That does not mean that the memories disappear entirely. They can influence behaviors and can impact our relationships without us realizing it. Most important, repressed memories can show up in our lives in the form of reenactments.

It can be especially painful for clients to admit that someone they loved, and who they believe loved them, could traumatize them by being abusive or neglectful. Sometimes, instead of facing the truth they consciously suppress the memories of what happened. This was the case with my client Chloe:

“It’s not like I ever forgot about the sexual abuse. I just chose to lock it away and throw away the key. I couldn’t handle the fact that my own father, who I loved dearly and who was the only person in my childhood who was kind to me, could harm me in that way—could be so selfish to put his own needs ahead of mine like that.”

Dissociation

Another reason a client may have no memories or only vague memories of a trauma is the common practice of victims to dissociate. Some victims dissociated, while others were traumatized so severely that they lost all memory of the attack—much like car accident victims often experience amnesia after the crash (repression).

According to the Diagnostic and Statistical Manual of Mental Disorders 5th edition, dissociation is a “disruption of and/or discontinuity in the normal integration of consciousness, memory, identity, perception, body representation, motor control and behavior.” Dissociation is a normal phenomenon that everyone has experienced. Examples of mild dissociation include daydreaming, “highway hypnosis,” or “getting lost” in a book or movie, all of which involve “losing touch” with an awareness of one’s immediate surroundings.

During traumatic experience such as crime victimization, abuse, accidents, or other disasters, dissociation can help a person tolerate what might otherwise be too difficult to bear. In situations like these the person may dissociate (detach or disconnect) from the memory of the places, circumstances, and feelings surrounding the overwhelming event, thus mentally escaping from the fear, pain, shame and horror.

When faced with an overwhelming situation from which there is no physical escape, a child may learn to “go away” in their mind. Children typically use this ability as a defense against physical and emotional pain or fear of that pain. By the process of dissociation, thoughts, feelings, memories and perceptions of the trauma can be separated off in the mind. This allows the child to function normally.

For example, when a child is being sexually abused, in order to protect themselves from the repeated invasion of their deepest inner self they may turn off the connection between their mind and body creating the sensation of “leaving one’s body.” This common defense mechanism helps the victim to survive the assault by numbing themselves or otherwise separating themselves from the trauma occurring to the body. In this way, although the child’s body is being violated, the child does not have to actually “feel” what is happening. Many victims have described this situation as “being up on the ceiling, looking down on my own body” as the abuse occurred. It is as though the abuse is not happening to them but just to their body.

While dissociation helps the victim to survive the violation, it can make it difficult to later remember the details of the experience. And it can make it difficult for a victim to come to terms with whether or not they were actually abused. If someone was not in their body when the abuse occurred, it will naturally affect their memory. For example, in the case of sexual abuse, if the person doesn’t “remember” the physical sensations of what the abuser did to their body or what they made to do to the abuser’s body, it can cause them to doubt their memory and add to their tendency to deny what occurred.

Tragically, ongoing traumatic events such as abuse are often not one-time events. For those who are repeatedly exposed to abuse or neglect, especially in childhood, dissociation is an extremely effective coping mechanism or skill. However, it can become a double-edged sword. While it can protect clients from awareness of pain in the short-run, a person who dissociates often may find that in the long-run his or her sense of personal history and identity is affected.

Grounding is a very effective practice to teach clients to help them come out of this dissociative state.

Basic Grounding Exercise

  • Find a quiet place where you will not be disturbed or distracted.
  • Sit up in a chair or on the couch. Put your feet flat on the ground. If you are wearing shoes with heels you will need to take your shoes off so that you can have your feet flat on the ground.
  • With your eyes open, take a few deep breaths. Turn your attention once again to feeling the ground under your feet. Continue your breathing and feeling your feet flat on the ground throughout the exercise.
  • Now, as you continue breathing, clear your eyes and take a look around the room. As you slowly scan the room, notice the colors, shapes, and textures of the objects in the room. If you’d like, scan your eyes around the room moving your neck so you can see a wider view.
  • Bring your focus back to feeling the ground under your feet as you continue to breathe and to notice the different colors, textures and shape of the objects in the room.
  • This grounding exercise will serve several purposes:
  • It brings awareness back to the body, which in turn can prevent being triggered or dissociating.
  • It brings us back to the present, to the here and now; again, a good thing when being catapulted back into the past by a memory or a trigger.
  • Deliberately focusing the attention outside yourself by being visually involved in the world helps bring a person out of a dissociative state and into reality where they can get in touch with their emotions and their memory.

Dissociative Amnesia

Dissociative amnesia is the inability to recall autobiographical information. For example, Betrayal Trauma Theory holds that for incest survivors, dissociative amnesia serves to maintain connection with an attachment figure by excluding knowledge of the abuse (betrayal blindness). This, in turn, reduces or eliminates anxiety about the abuse, at least in the short run.

Betrayal Trauma Theory is based on attachment theory and is consistent with the view that it is adaptive to block from awareness most or all information about abuse (particularly incest) committed by a caregiver. Otherwise, awareness of the abuse would acknowledge the fact that a betrayal occurred, and this acknowledgement would likely endanger the attachment relationship. Betrayal blindness can be viewed as an adaptive reaction to a threat to the attachment relationship with the abuser and thus explains the underlying dissociative amnesia in survivors of incest. Under these circumstances, survivors often are unaware that they were abused, or will justify, or even blame themselves for the abuse. In severe cases, victims often have little or no memory of the abuse or complete betrayal blindness. Under such conditions, dissociation is functional for the victim, at least for a time. (4)

Due to dissociation, dissociative amnesia or betrayal blindness, someone experiencing reenactments may have to trust the fact that they wouldn’t have the symptoms they have and wouldn’t have the deep sense that “something happened” unless they actually experienced a trauma. Other times some education can help clients to come out of denial:

The Lack of Specific Memories

The lack of specific memories can cause former victims to question their sense that something happened to them and even the flashes of memory that they do experience. Let’s compare this lack of specific memories with what often happens when someone has been in a traumatic car accident. Let’s say that you wake up to find yourself in the hospital. You notice that one of your arms is in a sling and that one of your legs is in a cast and that you have cuts and bruises all over your body. There’s no one around and you feel panicked, thinking, “what happened to me?”

Then someone you know comes into your hospital room and tells you that you were in a horrible car accident. You feel shocked because you have absolutely no memory of it. Not only that, but you can’t remember anything just before the accident. Just because you have no memory of the accident doesn’t mean that it didn’t happen, right? You have the broken bones and the bruises to prove it.

The same is true of childhood abuse. A client may not have any memories, but they have the results of the abuse as proof that it actually did happen. They have nightmares, flashbacks, and triggers, and they have self-destructive behaviors. If they were neglected or emotionally abused they may have low self-esteem, a tendency to be self-critical, or a tendency to push people away or, conversely, a fear of abandonment. If they were physically abused, they may have a tendency to be defensive or have rigid posture and a startled reaction when someone comes up behind them. They may have the habit of gritting their teeth, or tension in their jaw from all the repressed anger they are holding. In the case of child sexual abuse, they may have the unexplained pain in their vagina or anus, a negative reaction to being touched on certain parts of their body, powerful reactions when they see a movie about someone being raped or about a child being molested. Certain types of sexual acts or positions, or certain kinds of touches may repulse them, or they may dissociate when they are around certain people, places and things. These are, in essence, their “memories.”

The bottom line is that a client may never have actual “memories” in the sense of being able to “remember” or “recall” actual events. But that doesn’t mean they weren’t abused. Many of the clients I have worked with who do not have tangible memories have other indicators that they were abused. Some have flashbacks, others have what are called “body memories.” Those who were physically abused often have pain in the places where they were beaten, such as their back and buttocks. They often have a “startle reaction” when someone raises their hand in front of them due to the fact that they were slapped or hit in the head so often.

Those who were sexually abused can have pain in their genitals, anus, or breasts for no apparent (or medical) reasons and vaginismus (involuntary contractions of the vaginal muscles preventing penetration or making penetration extremely painful). Still others have such tell-tale symptoms as being repulsed by thoughts of sex, a fear of sex, an inability or repulsion to being touched, obsessive rape fantasies (either of someone forcing sex on you or you forcing yourself on someone else), or sexual addictions.

A Real Compulsion

It is important to understand that traumatized people experience a true compulsion to repeat repressed experiences. Even if the person attempts to keep the memory repressed, there is an opposing need on the part of the psyche to force the repressed material into consciousness. Thus, the repressed and dissociated events emerge to be re-experienced, often in dreams and nightmares (during sleep when conscious control must be let go), and then in waking hours as well. Clinical experience suggests that the compulsion to repeat takes on an almost biologic urgency, such as our need to urinate. We can hold our urine for only so long.

Examples of the Emergence of Repressed and Dissociated Experiences

Flashbacks are the most striking examples of repressed and dissociated trauma, and are frequently observed in clients with posttraumatic disorder, and some dissociative disorders. Flashbacks are involuntary recurrent memories in which an individual has a sudden, usually powerful, re-experiencing of part of a trauma or elements of a past trauma. These experiences are often frightening, catapulting the person back in time.

Those who are experiencing flashbacks are thrust back into the traumatic events both in their dreams and while awake. The reliving of the trauma is experienced as a real and current event. The traumatized person does not feel as if they are remembering the experience but instead, they feel the experience in the present. When someone is experiencing a flashback, they often lose awareness of their surroundings and are thrust back into the trauma, visualizing previous surroundings and people, and feeling they are the same age as when the trauma originally occurred. This points to the ability of the psych to repress and dissociate overwhelming experiences, as well as to bring them back into consciousness with full force.

Implicit Memories
Trauma “memories” often manifest in intense physical, perceptual, and emotional reactions to everyday occurrences and objects (triggers). These emotional and physical responses, called “implicit memories,” keep bringing the trauma alive in a former victim’s body and emotions again and again, often many times a day. Their bodies tense up, their hearts pound, they see horrifying images, and they feel fear, pain or rage. They freeze in fear or feel a sudden wave of painful shame and lose the capacity to speak. They feel an intense impulse to run away and hide from others.

Decades of research on the effects of trauma confirm that overwhelming experiences are less likely to be recalled as a series of images that we can describe or in a clear coherent narrative. Trauma is more likely to be remembered in the form of sensory elements without words—emotions, body sensations, changes in breathing or heart rate, tensing, bracing, collapsing, or just feeling overwhelmed. (5) When implicit memories are evoked by triggers, we re-experience the sense of threat, danger, humiliation or impulses to flee that we experienced at the moment of threat—even if we have no conscious verbal memory of what happened.

Those who insist that they do not remember any trauma often don’t realize that they are, in fact, remembering when they suddenly feel startled or afraid, when they feel shame or self-hatred, or when they start to tremble or shake. Because trauma is remembered emotionally and somatically more than it is remembered in a narrative form that can be expressed verbally, former victims often feel confused, overwhelmed or crazy. Without a memory of words or pictures, they do not recognize that what they are feeling is memory.

Most people also do not realize that we remember in different ways. With the thinking brain we can remember the story of what happened but without a lot of emotion connected to it. With our sensory systems we can remember how something felt. Our bodies might remember the impulses and movements and the physical sensations (tightening, trembling, sinking feelings) experienced at the time.

For example, many former victims feel uncomfortable stating that they were sexually abused because they do not remember whole events. Their memories are fragmented or unclear or consist of a few images, rather than an entire mental video of the events. They doubt themselves and think, “it can’t be true because I don’t remember exactly what happened” or “I must be making this up or I would remember more clearly.” But it is important to explain to clients that trauma cannot be remembered the same way other events are recalled because of the effects trauma has on the brain. When clients feel the impulse to doubt their memory or intuition that something happened to them, remind them that recalling events as a story or narrative is not the only way to remember. They may be remembering a lot more than they think.

Triggers

Your clients may feel surprised to learn how much they remember when they include the feelings, thoughts and physical reactions they experienced when triggered. Generally, a trigger can be defined as any stimulus that causes a reaction, often an emotional response such as anxiety, sadness, panic, feeling overwhelmed, flashbacks, nightmares, or severe emotional distress. A trigger is sufficiently reminiscent of a past event or process that it activates implicit (feelings, sensations, and nonverbal thoughts) or explicit (the what, when, and where of remembered events) memories in the present.

Types of triggers 
There are various types of triggers, including:

  • Sensory: sounds, smells, textures, or physical sensations
  • Time-related: certain times of day or seasons
  • People or places: people or places that remind them of a negative experience
  • Bodily sensations: pain or touch that reminds them of a negative experience
  • Substance-related: cravings or urges to use substances

Clients may also feel surprised to learn that there is an explanation for their seeming “overreaction” to certain things. For example, maybe they aren’t an “angry person,” but are simply experiencing feeling memories of anger that have been triggered when someone is selfish, controlling, or domineering.

Exercise: Discovering Your Triggers

My aim, in part, of writing this article is to help those of you fellow therapists who have clients who can’t make the connection between their past trauma and their current negative patterns of behavior either due to lack of memory, denial or minimization.

The following exercises and lists can help your clients discover their triggers:

  • Begin by asking your clients to notice the events, sensory experiences, or people that tend to trigger them (catapult them into the past, remind them of an abuse experience or some aspect of an abuse experience). For example: those who were traumatized by parental abandonment may become triggered every time a friend doesn’t respond to a phone call or text or every time their partner goes away on a business trip.
  • Next, ask them to begin making a list of these triggers.
  • As time goes by ask your clients if they see patterns regarding the things that trigger them.

Triggers List 

The following is an extensive list of triggers common for those who were traumatized by child abuse, abandonment, and/or neglect. Sharing this list with your clients and asking them to put a check mark next to the items that trigger them will help them become familiar with their triggers and in turn help them make the connection between their past trauma and their present reenactments.

  • Feeling abandoned or rejected
  • The sound of someone crying
  • Criticism
  • Someone being very angry
  • Someone saying mean or abusive things to you
  • Someone yelling at you
  • Someone raising their hand or fist near you
  • Someone threatening to hurt you
  • Mean or dirty looks
  • Seeing violence on TV, at the movies, or on the Internet
  • People in authority
  • Competition
  • Being lied to
  • Someone acting like they are better than you
  • Someone who reminds you of your mother
  • Someone who reminds you of your father
  • Being let down by someone
  • Being laughed at
  • Being accused of something you didn’t do
  • Being ignored
  • Feeling alone

Remind your clients that their symptoms and triggers are their memories. This is what my client Briana figured out after reading the triggers list from above:

“I was shocked to realize how many triggers I experience, almost daily. In some cases, I had been aware that some situations were upsetting for me, but in other cases I was completely surprised when I realized I was being triggered. For example, I’d been aware for a long time that I had abandonment issues due to my mother leaving me all alone with our father. I hated to be alone, and I always reacted strongly when my Dad went somewhere for any period of time. But I had blocked out the memory of what it was like before my mother left me.

When I read “the sound of someone crying,” on the trigger list, I became really upset. I suddenly realized it had always been a trigger for me, and I understood why. I suddenly remembered my mother crying for hours, almost every night. I’d completely blocked that out. Suddenly I not only remembered her crying but the reason she was crying. I remembered hearing my father yelling at her, accusing her of being unfaithful, of being a horrible mother, telling her I would be better off without her. That simple realization and the memory of how often I am triggered by hearing someone cry made it all so clear. My mother left me because she believed what my father had told her. Suddenly it all made sense.

“For years I’ve been reenacting the fact that my mother abandoned me. I always chose men who ended up leaving me or I would push men away who loved me, out of fear that they would abandon me. I knew on some level that it had to do with my mother’s abandoning me. But even knowing that didn’t stop me from behaving the same way. I’d always questioned how my mother could have done such a horrible thing. And I always blamed myself in some way. I assumed that I wasn’t loveable—that my mother couldn’t love me because I was such a bad kid. I acted out a lot as a kid, missing school, getting into trouble at school, that kind of thing. I assumed she left to get away from me, away from all the trouble I was causing.

“But remembering my parents’ constant fighting, and the horrible accusations my father threw at my mother explained it all to me. I knew how it felt to have him throw out accusations like that—he did the same to me all the time. And I knew how hard it was not to believe what he said. I could see how my mother had taken it all in and had come to believe that in fact, I would be better off without her. It wasn’t my fault at all. And it some ways it wasn’t hers’ either. It was my Dad’s emotional abuse that caused her to leave.”

Often, as it was in Briana’s case, what triggers your clients the most could be pointing towards what needs healing. Flashbacks can be messengers reminding us of what happened to us. In that way they should be considered our friends. They help us become aware of memories and feelings we have buried. In Briana’s situation, her reenactments had been due to her mother’s abandonment but more specifically her need to understand why her mother had abandoned her. Once she remembered why her mother left her, she no longer blamed herself and no longer needed to punish herself. She no longer needed to reenact the trauma of abandonment.
***

Hopefully, the information and exercises offered in this article can assist you in helping your clients determine whether they were, indeed, traumatized as a child or adolescent due to the abuse, abandonment or neglect they experienced and why they may be reenacting that trauma.

References

(1) Miller, A. (1984). Thou Shalt Not Be Aware. Meridian.

(2) Freud, S. (1961). Beyond the Pleasure Principle. Norton.

(3) Herman, J.L. (1992). Trauma and Recovery. Basic Books.

(4) Freyd, J. (1998). Betrayal Trauma: The Logic of Forgetting Childhood Abuse. Harvard University Press.

(5) Ogden, P., Minton, K., & Pain, C. (2006). Trauma and the Body: A Sensorimotor Approach to Psychotherapy. W.W. Norton.

©2025, Psychotherapy.net

Bethany Brand on the Identification and Treatment of Dissociative Identity Disorder

Lawrence Rubin: Bethany Brand is a professor of psychology at Towson University. She’s an expert in trauma, specializing in trauma related disorders, including post-traumatic stress disorder and dissociative disorders. She also maintains an independent practice in clinical psychology in Towson, Maryland. Doctor Brandt serves on international and national task forces developing guidelines for the assessment and treatment of trauma disorders. Welcome, Bethany. Thank you for joining.

Bethany Brand: Thank you so much for having me.

Right Place, Right Time

LR: What got you interested in dissociative disorders, trauma, and ultimately dissociative identity disorder from a personal perspective?

BB: It was a number of things. One of the early experiences I had as an undergraduate at the University of Michigan was working in a shelter for women who’d been battered, which is what it was called back then—not interpersonal violence like we call it now. I started hearing about trauma and remember being very interested in it. In my first semester of graduate school, I was doing a psychological testing practicum at Johns Hopkins Hospital on the kids’ unit. This was in the late 80s, so many of the kids had been abused or neglected according to their charts. I asked my supervisor how that experience might be reflected in their psych testing—how would they be different? And there we were at Hopkins, one of the premier institutions in our country, and she did not know.

To her credit, she acknowledged that and asked her supervisor, who later gave us this fascinating off-the-cuff talk about trauma and his experience with traumatized kids. It was so compelling that I decided that was what I wanted to do my master’s thesis on. I was lucky enough at the time that Frank Putnam, one of the legends in the field of dissociation, called my graduate program, asking for students who might be willing to volunteer on his project—a longitudinal study of girls who’d been sexually abused. I was incredibly lucky to be at that right place at the right time, working with a pioneer.

To be honest with you, I wasn’t sure about the whole idea of dissociative identity disorder because we didn’t see that in the lab and that was not what we were studying, even though Frank was studying it at the National Institute of Mental Health. When I later went on internship at George Washington University Hospital, a woman there said she had multiple personality disorder, with whom I had done the testing.
The treatment team was a little skeptical, but my supervisor referred me to Judy Armstrong at Sheppard Pratt Hospital in Baltimore who offered to review the data with me. After she did so, she said, “You know what; you actually might have somebody with MPD.” After that, it was just luck because I got a postdoctoral fellowship at Pratt, where they had just opened up a trauma disorders unit, and where I did my dissertation on trauma. I remained there and began working very heavily with folks with DID, and other serious, complex trauma disorders. Right place, right time, and fortunately, amazing training with amazing clinical supervisors.

DID and the Dissociative Spectrum

LR: Before I ask you what readers most likely want to know, which is, “What actually is DID,” why the transition from “multiple personality disorder” as a label to, “dissociative identity disorder?”

BB: There were a lot of reasons, but just to be very brief; by calling it multiple personality disorder, many clinicians thought it was a personality disorder like borderline personality disorder, and it’s not in that category. The experts in the field wanted to emphasize it was a trauma related disorder connected to dissociation, not a disorder of personality. The name change was an attempt to reflect that.

LR: Well, I guess relatedly—and I may get back to my initial question—does the DSM’s characterization of DID as a complex post-traumatic developmental disorder, ‘capture it?’

BB: It’s a terrific start. It’s a foundational start, because it implies that it starts in childhood, which is what developmental disorder means. The research strongly points to very early severe chronic child abuse as the cause. But we also know that there is genetic tendency towards dissociation. And often these clients who end up as individuals who develop DID also have attachment problems because they didn’t have secure attachment. There are multiple things going on, but trauma really has an early childhood foundation.

LR: In your writing, you discuss TRD or trauma related dissociation and suggest that DID is almost always related to early childhood trauma and severe disruption of the attachment relationship. Is there such a thing as a NTRD, or non-trauma related dissociation?

BB: Yes! We all dissociate to some extent, so normal non-pathological dissociation can occur. It can be going into a state of automatic pilot. For example, when we’re driving down the highway and we’re really thinking about something, and barely remember the drive when we get home. Or we’re driving down the highway and we miss our exit because we’re so preoccupied, not because of traffic, but because of our mental disconnection from what we’re doing.

It can also happen at moments of peak spiritual experiences or athletic experiences when people can disconnect from their bodies or feel out of their bodies and have this incredible experience. But none of these experiences interfere with functioning.

LR: I imagine getting lost in a book or a song or a movie or a conversation containing elements of dissociation, but on the left side, or benign side of the spectrum.

BB: Exactly. Those are called absorption, and some people are very prone to absorption. We know from research that the more somebody is prone to absorption, they may be more at risk for dissociation. There’s been some debate over whether absorption should be called dissociation or not? For now, it is understood as one of the lower levels, not-so-problematic types of dissociation, which comes from self-report measures.

LR: Is it clinically useful to think of a dissociative spectrum with absorption type experiences on the left or benign side, and DID as the most extreme and pathological form all the way to the right?

BB: Yes, I think it is. But I’ll say that with awareness that some people living with DID really resent that, because understandably, this was an adaptation to horrendous, overwhelming circumstances. And so, I completely get it and respect that they had a brilliant way of adapting and getting through what would have been just harrowing experiences. The research actually supports exactly what you said.
As I said earlier, all of us dissociate to some extent. And then when you start studying dissociation and different psychological disorders, there’s a range of scores that people have on the different, self-report questionnaires. And it starts out with people having [scores] a little bit above what might be for people who are not struggling with any emotional disorder.

And then it gets at the highest level is folks with DID. And in between, there might be people with eating disorders and maybe borderline personality disorder, because there’s often a lot of trauma in those people’s background, and then you start getting into PTSD. And then the dissociative disorders indeed are at the end with the highest levels of dissociation.

LR: I would think that someone who is engaging in non-suicidal self-injury or someone who is in the middle of an intense food or substance binge is in an acute state that requires a certain amount of dissociation to be able to inflict that level of harm on to yourself.

BB: Is there some dissociation that goes on during those moments? The answer is yes! Often people are somewhat disconnected from their bodies. An example is a client who, with DID or severe dissociation, may be cutting and not feel it and be kind of fascinated with what they’re seeing under their skin, like really extreme cutting with the detachment. And they don’t feel the pain.

LR: Is it possible that someone with DID could be cutting while there’s another element of that personality that’s watching? Am I using the right nomenclature for the other “states?”

BB: There are people in the field that are really pushing for those parts to be called dissociative self-states. In the literature, they’re alternatively called identities, personalities, parts, and alters. We’re really trying to emphasize that whatever they’re called, that they’re all parts of one person. They’re self-states. They’re not different people. That’s why we’re encouraging that name to be adopted in the next DSM.

LR: I find myself gravitating toward more questions that may be more of a popular culture artifact, but I’ve heard that different self-states can have symptoms of a particular medical illness or disease while another is asymptomatic. Is that possible in your experience?

BB: It depends on what illness you’re talking about. We know that, depending on our emotional state, our blood pressure may change, right? And Frank Putnam, who I referred to earlier, did some of the early research showing that different self-states have different EEG patterns.

Simone Reinders in the Netherlands has done a bunch of research studying neurobiological differences among some self-states. She’s tried having professional actors impersonate self-states while they were hooked up with all kinds of biological markers, including brain scans. They could not emulate different self-states.

It’s remarkable. It’s not magic. It’s a disorder that is linked to neurobiological changes and differences. And of course, these different self-states are going to include the traumatized self state, the one that remembers trauma and has all the symptoms that go with that PTSD. When they’re scanned, of course you might expect their heart rate to be much faster and for them to have more activity in their limbic system, versus a part that’s very detached and doesn’t recall that trauma. The heart rate of that self-state is not going to be as elevated. And they’re not going to have the intense amygdala activation.

LR: I can see that if someone is in a moment of active sexual abuse, sexual trauma, that it’s in the body’s interest to down-regulate the heart rate and cortical activation.

BB: Yes. There are studies about that, talking about how animals go into survival mode and, you know, like the faint mode or the feigning death mode. There are some animals that have that response of total disconnection from their bottom up to allow them to survive attack. Well, there’s some parallels with humans that have been horrendously abused repeatedly. Their brains shift into dissociation as a survival mechanism.

Their access to memory can be quite different as well. One of the diagnostic requirements is that there be amnesia for some of their life experiences, that are not due to drugs, alcohol, or head injury. Or they may not remember key autobiographical events, like their own wedding. We call that dissociative amnesia.

LR: What are some of the myths and misconceptions about DID that clinicians should know about?

BB: There are a lot, unfortunately. One is that DID is exceptionally rare. On and across different prevalence studies, at least 1% of the general population meets criteria for DID. That’s the same prevalence rate roughly as bipolar disorder and schizophrenia. So, it’s not rare, but there have been some critics.

Critics of the whole notion of dissociation and DID have been putting it out for a long time in articles that are published in journals. And that has found its way into psychology textbooks that undergrads and grad students read that put forward that myth so that unfortunately, many people, even mental health clinicians, think it’s rare. Another myth put forward by the critics is that DID folks exaggerate their symptoms or are prone to create false memories of abuse.

When you actually compare people with DID to people with PTSD to what are called healthy controls, people who don’t have any emotional problem, and professional actors who try and emulate all of this stuff, there are some studies we’ve done that show that people with DID
are no more likely than people with PTSD to develop false memories.

The important thing that most mental health clinicians have not been trained to know is that they are highly symptomatic across a bunch of different domains. They don’t just have amnesia and different dissociative self-states. They also have PTSD. And we know PTSD is a complicated disorder with 17 potential symptoms. And so, at times they’re flooded with traumatic intrusions, pictures, awful memories, awful nightmares. And then there’s periods where they’re shut down and avoid it because it’s so awful to remember and feel that stuff.

And then there can be incredible periods of irritability and sleeplessness and feeling like they’re an awful person and different from the rest of the world. There’s a lot of research showing that dissociation is very common among people with PTSD. They also have major depression and because living with all these symptoms is so brutally difficult, many of them have substance use problems.

They try to knock out the memories by drinking too much or using drugs. They often also have eating disorders because they have a very difficult time tolerating their bodies. They blame their bodies for their abuse, and so they try and get really big so that nobody’s ever attracted to them or—and they often go back and forth, or they get really anorexic and starve themselves hoping to die or to look unappealing that way.

All of that is shown in the literature. And with regard to feigning DID, one of the ways that you look for malingering is when somebody is reporting too many symptoms or reporting exceedingly severe symptoms. They are much more likely to be classified as potentially malingering on some of the evidence-based measures and interviews for malingering. I’ve developed research that helps mental health clinicians and forensic experts know how to differentiate when somebody has true DID and when somebody is attempting to simulate it.

The critics also don’t really understand complex trauma. They are typically not clinicians or academics. But because so few mental health folks are getting trained in the evidence-based information about DID, they come away with these stereotypes out of textbooks that are just wrong. They’re just flat wrong. And myths.

LR: Is there a short list of the cardinal presentations that differentiate DID from some of the other severe forms of psychopathology?

BB: Back when I was trained, I was taught that if you hear voices, you are psychotic. But more than 75% of people who have DID hear voices.

LR: Schizophrenic?!

BB: Yes, schizophrenia or maybe the psychotic phase of bipolar disorder. I would encourage therapists to not automatically assume that hearing voices means psychosis. There’s a whole bunch of research, including people who don’t have DID, experience voice hearing, and this is strongly associated with trauma exposure. There have been meta-analyses that support this, so I suggest that clinicians always ask every client, no matter the setting, if they have been exposed to trauma. So, learn how to do a good trauma assessment.

If somebody endorses having experienced trauma, then ask about PTSD symptoms and dissociative symptoms. Ask about the different types of dissociative symptoms. Ask about depersonalization. Does the person ever feel numb when they should have feeling? Does the person ever feel like their body doesn’t belong to them? Do they ever see themselves at a distance, like outside of themselves, like they’re watching a movie? Those are three common symptoms of depersonalization, and there’s a range of other symptoms they can ask about, like do you sometimes feel like you’re younger or not your own biological age. Ask about voice hearing.

LR: What’s your gut feeling about why there’s such resistance among clinicians to embrace the reality of DID?

BB: It does sound farfetched, right? But that’s because people are misunderstanding the disorder. It is impossible for people to have multiple people inside themselves. It is impossible. Right. But, Lawrence, you don’t have a little Lawrence running around in your brain, and I don’t have a little Bethany running around in my brain. How do you know you’re not me?

LR: I’ll have to check.

BB: I stump my students when I ask that question. You know who you are because you know that you have a cat and that you’ve been married and lived in Michigan, and that you like Hello Kitty, and that you like certain kinds of music and food, and you have knowledge and memory of family and life experiences. But people with DID don’t always feel like all that.

First of all, they have periods of time missing. And so, they’re confused about who they are and what’s happened in their lives. But they’re not different people inside. Now, I’m going to say that, and some of the readers who have the idea are going to object to what I just said, because some people with DID do feel like they are different people.

That is their perceived experience, but people with DID don’t literally have little people running in their heads either. Our personalities are based on the neural firing of networks in our brains. And like we were saying earlier, there’s a neurobiological pattern that is characteristic for trauma related self-states versus ones that are very detached and don’t remember the trauma.

So, I think a lot of mental health people are mistaken and don’t understand what they have heard. It’s rare and I’ve been told this so many times, “Doctor Brand, I’ve been in the field for 30 or 40 years, and I’ve never seen a DID patient.” But I guarantee you, if they’ve really seen a lot of clients, they actually have, but missed it because perhaps they’re looking for dramatic presentations like Sybil. If it was that obvious, then when people switched states, it would be easy to diagnose. But that’s what movies do to make it look right to the audiences. That is not actually what DID really looks like.

A Tiered Approach to DID Intervention

LR: What is a multi-phasic approach to intervention with DID, and why is it considered the gold standard?

BB: It means that clinicians who work with DID and other serious dissociative disorders are realizing that there needs to be three stages of treatment. When somebody comes into treatment with complex trauma, and especially if it’s very serious, there needs to be an initial stage of stabilization of their symptoms. At this early stage, they may be suicidal, self-harming, drinking and using drugs, or engaging in some other kind of addictive behavior.

They often have really high levels of hospitalization, so they need to learn other ways of regulating themselves that are safe and that they can do out of the hospital. If and when they get stabilized, they begin learning how to regulate emotions in ways that ground them, which is the opposite of dissociation.

Once they’re stable and want to go on to stage two work, we are talking about trauma processing. That’s where they may then talk about some of the trauma so that gradually they can heal from that and not have so many intrusions of nightmares and flashbacks and horrible memories or feeling numb to it.

It’s an awful thing to feel like you’re deadened inside. That would be stage two work, which can take a very long time. So can stage one, by the way. And then comes stage three. For complex trauma—and I’m not just talking DID now—but in general, the person works more on developing their life, their friendships, their career goals; they’re no longer so focused on the past and trauma, but integrating into whatever kind of life and relationships they want.

LR: Is this in line with your “Finding Solid Ground” program?

BB: Yes. The program I’ve created with colleagues called “Finding Solid Ground” is a staged stabilization approach where we help clients learn about, first of all, grounding. But it’s not just for people with DID, but also for people with complex PTSD, and what in the United States is called the dissociative subtype of PTSD.

Our research is showing it helps all these folks, not just DID, but they learn to be more present to their emotions and deal with emotions in healthier ways. They learn about how to deal with PTSD so it’s more contained and not so intrusive so they can sleep better so that they’re not having these awful images pop into their mind and interrupt their functioning all day.

We help them learn to separate past and present. When somebody has very bad PTSD, the brain cannot really distinguish the difference between a flashback and the present moment. It feels to the person it is happening now. So, we teach them how to catch their warning signs that they may start being close to being at risk for intrusions of PTSD, that they might start dissociating, that they might start drifting towards self-harm, and then find ways to get out of that cycle. Among other things, we teach them a little bit about the neurobiology of trauma and that it’s not their fault.

LR: Is integration of self-states the absolute end goal for treatment?

BB: When I first accepted that postdoc at Sheppard Pratt in 1993, the emphasis in the field was integration of personality states. And yet that’s not what I was hearing and seeing was happening very often. I was the leader of a study where we asked experts around the world how many patients had they integrated in their careers. It was small numbers.

That may not sound like a jolt of lightning to readers, but it did lead us to rethink whether that was very achievable for most patients or not?

At the same time, many people living with DID do not want to integrate their parts because they have lived often for decades with these parts. And that helps them function from their perspective. That is who they are. They value their parts, or eventually you hope that therapy can help them learn to respect and value their parts rather than be at war. Some of the self-harm and suicide attempts are about one part trying to kill off another. At the time, they don’t recognize they will all die if they commit suicide. So now I have a different perspective and I think there are different options. I think clients should have the right to choose what they want their endpoint to be.

And that may change over treatment. In the beginning, some clients absolutely say get rid of these parts, but they don’t understand. They can’t. I use the metaphor that you can’t live by cutting out your heart or your liver. And it’s the same thing with self-states. You have survived because of the self-state. You can’t get rid of one. You can learn to work as a coherent collaborative group like a business or a healthy family rather than being at war.

DID and the Family Connection

LR: Are there useful systemic interventions that involve family, spouses, children?

BB: Of course, as a therapist, I’m teaching them, but I don’t want their spouse or partner to be doing therapeutic things. Right! But it gets really messy. If they have children who see them switch, and mom or dad doesn’t seem to remember things they’ve said or done, I find ways to explain DID to the kids in an age-appropriate way.

It is incredibly important that they’re not switching a lot in front of their children. Parents should be consistent no matter what, no matter who they are, whether they have DID, bipolar disorder, or PTSD. Children need consistency. So I would work with a client to help them develop the parenting parts and having them learn to look similarly and act similarly with the kids, so they’re not confusing the kids.

LR: In this context, can a person with DID voluntarily call on another self-state, rather than it “taking over” during a time of crisis or trauma-related moment?

BB: Yes. So that might be something that we’d work on, to go back to that last example, when they’re around their children. You would want them to work towards having parts that can be very supportive, caring, loving, consistent parents. And the parts that are little, that feel as if they are young children, terrorized, traumatized themselves, would be in the back of the mind.

All this is metaphor, however, right? There are no little people, right? But metaphorically, those self-states are taken care of internally so that they are consistent. Same thing with work, same thing when they’re driving.

LR: You said earlier, Bethany, that invariably, dissociative states and DID in particular are born out of severe trauma in childhood and attachment disruptions. At what point might a clinician begin to suspect dissociative identity disorder in childhood?

BB: Really good question. Some of the same symptoms that later develop and become more severe in adulthood can be seen in little children with the beginning stages of a dissociative disorder. One thing I haven’t mentioned is that adults with DID can go into trance states where they’re not responsive to the outer world.

Little kids start showing attention and zoning out. They’re often misdiagnosed as having ADHD. So again, we need all clinicians to be trauma-informed and trained. Not that they’re expecting to see a dissociative kid, but they might, especially if they have symptoms of PTSD like nightmares and flashbacks, or report having imaginary friends. Some talk about that for a second.

Developmentally, it’s normal for children to have imaginary friends. But if imaginary friends start to be frightening, or upsetting, or tell the child to hurt their sibling or a pet, or to destroy their toys, that’s not a “normal” kind of scenario. Little kids usually stop talking about imaginary friends around age seven. But people with DID report that they never went away. Those actually linger as parts of their dissociative self-states.

Keyword, Avoidance!

LR: There are clinicians who believe that if we look hard enough for trauma, we will find it. Is it similar for dissociation and DID?

BB: It might be! During medical training, students commonly think they have all the different disorders. The same thing may be happening in our field. For 26 years, I taught a course on differential diagnosis and interviewing. At the beginning of the class, I warned the students that they were going to be tempted to diagnose themselves along with everybody they loved or hated. It is a normal phase of learning the DSM but I asked them to be respectful and stick to the diagnostic criteria, so they don’t go telling people they’ve got borderline personality disorder.

There is a normal stage of training in which, at least for a while, we may overuse certain concepts as we’re learning them. But again, if clinicians are well-trained in differential diagnosis they will be less likely to overdiagnose certain symptoms and disorders—in this case, dissociation and DID. This is one of my research streams.

There is a lot of research out there, and I’ve written a book about how to assess dissociation and how to distinguish it from other symptoms and disorders. Here is where training is critical. The ways you treat schizophrenia and bipolar disorder are very different from the way you treat DID. Schizophrenia and bipolar are the two disorders that people with DID are most often misdiagnosed with.

People with DID don’t need mood stabilizers or heavy-duty antipsychotics. Instead, you do a trauma-informed stabilization approach. Two of my earliest DID clients were misdiagnosed with schizophrenia and treated accordingly for years. One passed away and gave me permission to share her story. By the time I saw her, she had horrible tardive dyskinesia. She had been disfigured by the treatment for schizophrenia that she didn’t have. Once we started working together, she got a lot better— not cured, but a lot better, and she was much more functional. She had dropped out of school and midway through high school, she went back and became a minister in her community.

LR: What do you see as the core elements of training that need to be incorporated into graduate programs so that DID can be correctly identified, and interventions designed?

BB: Only 8% of APA-approved doctoral programs require a course in trauma. That’s gotta change. Information about trauma should be a required part of graduate training in psychology, social work, and related fields. As part of that training, they also need to learn about dissociation and the range of dissociative disorders, and how you assess for dissociative disorders, and how you do differential diagnosis. And, of course, something about evidence-supported treatment. There’s only one program so far based on randomized controlled trial data that shows it helps people with profound dissociative disorders. But they should hear about that. That should be in the textbooks.

LR: What do you think is contributing to that incredible avoidance by the APA of mandating graduate-level trauma training at graduate level?

BB: A group of us have been pushing for different guidelines about working with complex trauma that finally got approved by the APA this last summer. But there is pushback. And a lot of us think there’s a political issue. Let’s just think about what PTSD means. The required criteria center around avoidance. You nailed it there!

Even people who’ve been traumatized don’t want to think about it. It’s human nature not to want to know, think, and talk about trauma. Believe me, it’s a hard part of my job. I do it, and of course I know how to do it. But hearing the stories of what has happened to little children is incredibly difficult.
And there’s some real doubters out there when it comes to thinking about child abuse. Maybe they should read a little bit about child pornography and child trafficking and how rampant they are, because we’ve got plenty of evidence that that happens. Some individuals report that part of their abuse was being the victims of child pornographers.

So, I think we don’t want to think about that stuff!

LR: Avoidance on a large scale.

BB: Avoidance. You nailed that.

LR: Not to get sidetracked, but I wonder if this is what Bessel van der Kolk experienced when he tried to get his developmental trauma disorder approved by APA.

BB: I’m sure that’s some of it, but not-unshockingly, it likely goes back to financial issues.

LR: It’s hard to imagine.

BB: At this point, the National Institute of Mental Health has never once funded a study of the treatment of DID. So, I have literally had to get donations to fund my studies. Do you think cancer researchers do that? Do you think researchers of any other disorder must have bake sales and pass the plate at college?
Where is the money in trauma right now? It’s in the Veterans Administration. I’ve heard this from various people who work there. They do not recognize DID, and they don’t want anybody in the VA system being diagnosed with DID, because that’s a real problem for our military, right? Everybody there has a dissociative disorder. Although believe me, I have assessed people in that system and helped them get honorary discharge. Anyway, there’s a huge amount of funding that goes to VA research and they emphasize working with adults. They want to keep the soldiers “strong” and ready to go or whatever the branches to ready to fight. Yeah. The childhood trauma.

LR: It’s hard not to introduce politics into conversations at this level. But do you have any concerns about funding for dissociative and other disorders as the incoming administration takes form?

BB: I do, and I think many, many researchers are very concerned about funding for new science research in general. But then when you get into groups like research on women, research on children, research on traumatized people, research on any kind of minorities, but especially LGBTQ groups, people are very worried. My funding has always been a problem. But I do have many generous donors.

Wrapping Up

LR: There’s so many big sales you can have, and winter is coming.

BB: So, we’ll have some hot chocolate sales and some coffee. Yes, there is a group called the International Society for the Study of Trauma and Dissociation (ISSTD). They do lots of multi-level, face-to-face and online training for dissociation and children, adolescents, and adults. They also supported RCT studies for our Finding Solid Ground program.

I’m strongly urging clinicians to learn about that program. We’ve got two books out there. One for people living with the disorder, and one for therapists. Our research shows that the Finding Solid Ground program works best when the therapist knows the program and the clients working with the therapist who knows the program.

LR: Has counter transference entered into your work with any particular client?

BB: For anybody working with complex trauma, there is going to be countertransference and traumatic countertransference. And the client will experience transference. There’ve been times I felt like I wanted to rescue somebody because they’ve had such a hard life. But you’ve got to keep the boundaries strong. I consult with a lot of therapists. One of the mistakes I hear from therapists is they do try and rescue, or they go too far. It’s not uncommon that therapists will see a DID client for free and become very burned out. I don’t ever advise that.

The psychotherapy research shows that people benefit from treatment more if they’re paying something. It’s also common for therapists to alternate between feeling helpless, like the child was back during trauma time, and at other times harsh and mean which the client may experience as harsh and mean, almost like the perpetrator or a non-protective bystander. Those three roles are extremely common in the treatment, so I teach a therapists to watch for that, to work on that, and to make that understood.

Something they actually talk about with their clients so neither get stuck in those spaces and can learn from it. It’s part of the healing, rather than becoming the point where the treatment comes off the rails.

LR: I think that we could talk for hours, Bethany. It’s been a fascinating conversation for me as I hope it was for you. Is there anything I’ve left out?

BB: Yes. There are people out there who have died because of this disorder, but there is hope, even despite the tremendous suffering. It’s important that these people know that they are not alone, and neither are their therapists. It’s important that therapists convey that they’re not alone, it’s not their fault, and that they are not weak or dumb. They don’t have to suffer endlessly, and neither do therapists need to feel powerless. There’s hope.

LR: I think the clinical world is a smarter place for your presence in it. Thank you, Bethany.

BB: Thank you!

Ethics or Protocol: Children Must Take Priority

A friend offered me the opportunity to join her in her practice, which I gladly did based on my knowledge of her values, beliefs, my love of what I do, and awareness of my weaknesses in marketing and billing. I brought my 20-plus years of clinical experience across inpatient, outpatient, and community mental health settings, which included my skills in assessment, documentation and play therapy into practice.

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I was happy as a clam doing the clinical work, receiving a regular paycheck, and leaving behind the hassle of finding clients for myself. In terms of emotional demands on my employer, I was a non-complainer, and my needs were few. I asked for little and consulted enough to keep her informed of significant treatment issues.

An Ethical Dilemma Arises

As the practice grew, so did my employer’s need to be outside the office, and in her place, there were protocols. One of them was that no written document was to leave the office without her review, which included all letters, reports, and clinical summaries. Clinicians had deadlines and due dates on the documents which left the office, which did not always coincide with her ability to review and approve them. I understood the need for this system with new employees and interns, and that with multiple employees, that was a lot of reviewing. After all, that is what supervisors are for! But as a seasoned professional, I was not new to the field, and I knew my way around documentation and ethics.

I was treating a court-related, post-divorce father with three children, who traveled out of state for visitation with their mother. It was a 10-hour drive. A Guardian Ad Litem, who also happened to be an attorney, was assigned to the case.

The mother had been asked/ordered to participate in treatment and met once with me along with the children. In that meeting, she expressed her resentment and never returned. The father, nanny, and I were sure that the children were being abused and neglected. The children were telling the father, nanny, or myself stories of inconsistent care with meals, medications, sleeping arrangement, and transient care and supervision outside of their mother with other extended family members.

We were documenting the children’s emotional state and physical condition prior to, and after their visits with the mother. I was working with the children individually, as a group, with the father, and/or the nanny, after visitation with the mother to further support the need for intervention to stop the visitation. The judge continued to order the visits for lack of evidence and threatened the father with jail time if he didn’t comply.

We were documenting signs of abuse and neglect; refusal to give medication for a documented health condition, untreated medical illness, injuries, abnormal bruising, weight loss, sleep disturbance, and neglect. The children were scheduled to travel out of state for an extended three week stay. The father was under a court order to send them and severely stressed by the prospect.

In my clinical opinion the children were in danger if they were sent out of state for an extended visit like this. I felt the need to inform the Guardian Ad Litem. The deadline for the childrens’ next departure was rapidly approaching.

At that moment in time, my employer was consulting out of state and not due back until after the children’s impending departure. I fully understood the importance of protocol that the employer had set in place, but there was so much more at stake here than protocol. There was the children’s safety, health, and wellbeing, not to mention my legal liability, that of the agency, and my ethical reporting responsibility. While many reports had been filed in the past, there was not enough hard evidence to file a DCFS report or stop the visit.

I had prior authorization to communicate with the Guardian Ad Litem. I wrote the letter to the Guardian Ad Litem expressing my concerns, and the reasons. Based on experience, I knew my employer would not review the letter before the deadline for the visit, even if I sent it through email. The internal debate was emotional but brief. I sent the letter to the Guardian Ad Litem, and put a copy in the file, knowing it could cost me my job. The children needed to come first.

Because of the court order, the father sent the children to their mother. I did not hear from the Guardian Ad Litem, who did receive it via email, before the scheduled departure. The children survived the visit. Shortly after their return, one of the children disclosed sexual abuse, giving the court enough legal grounds to end visitation. The mother’s parental rights were terminated. The father re-married, and all three children have been formally adopted by his new wife. The children are thriving and progressing developmentally, despite their challenges.

As for my employer and I; we parted by mutual agreement.  

Storytelling in Counseling Is Often the Key to Successful Outcomes

Clients come in all shapes and sizes, seeking services for a wide range of reasons. No two clients are alike. But I have noticed something that many of my clients seem to share when they first come to counseling: they all want to tell their story.

I mean, it makes sense. When I visit my medical doctor about my aching lower back and they want to know about physical symptoms, I, on the other hand, want to tell them the story of how my aching lower back came to be. When a client comes to counseling and I want to hear about mental health symptoms, they, on the other hand, want to tell the story of their mental health. People think in terms of stories. People live their lives in terms of stories. Memories are organized around stories, and hopes and dreams travel along narrative lines too. It’s no wonder why a client would want to tell their story when starting out therapy.

My Early Experiences

I didn’t always hold stories in high regard. When I first started out in counseling, I became rather annoyed with clients when they launched into what felt like a long-winded story. “Just answer my question” or “Just tell me the facts” I would think to myself. Stories, in my mind, were just ways for clients to frustrate me and drag out the process. I didn’t realize or capitalize on the therapeutic power contained within stories until I realized that stories are more than straightforward vehicles for communicating information.

Stories are a way for clients to share who they are. They are doorways for connecting with a client. They contain feelings, hopes, dreams, desires, fears, worries and more, all wrapped up in a narrative about the client’s major life experiences. I’ve come to realize that listening to a client’s story is incredibly important. As a counselor, I have slowly learned that I should not allow myself to feel rushed, or hurried by the demands of billing insurance, scheduling, lunch breaks, consultations, supervision, records requests, and the mounting unwritten therapy notes that await completion of the client’s story. Slowing down and listening to the client’s story is the key to exploring their intricacies.

The Therapeutic Power of Storytelling

There’s another dimension to storytelling, though, that I’ve haven’t mentioned. Storytelling is a two-way street. The client tells me their story, but I also tell the client their story back. Telling a client’s story to them allows them to reflect, to take perspective on aspects of their experience they may not have considered. Furthermore, I may highlight certain aspects of a story that the client often neglects or avoids. By listening with intent and curiosity, I can shine the spotlight on a client’s resilience and fortitude, even in the face of tremendous suffering and challenging circumstances.

But telling a client’s story doesn’t always have to be a matter of sunshine and roses, and may instead reflect the dark parts of a client’s narrative and life. It can be deeply affirming and validating for a client to hear their pain acknowledged, to know that what they went through mattered, and that it played a crucial role in shaping them. Storytelling is life-affirming. It coheres disparate elements of a client’s life into a continuous narrative that imbues them with a sense of purpose and meaning.

Storytelling in Practice

My perspective on the importance of storytelling’s role in counseling isn’t just theoretical. I’ve come to this view by working through the trenches of clients’ heartbreaking, tragic, bitter stories. One case in particular stands out. I remember working with a single mother of an especially challenging child. For his age, this child was very angry, aggressive, and prone to violent outbursts.

The mother attributed much of the behavior she saw in her child to the abuse and violence he witnessed from his father who was no longer in the picture. I worked with the family for some time, but it always seemed as though little progress was made. The mother, however, possessed an indomitable and unwavering belief in her son. Despite the family’s difficult past and her son’s concerning behavior, she saw strength and potential in him. She viewed their past as an opportunity to grow and develop in new patterns that would not resemble the abusive father.

“Defender of the Weak”

At particularly difficult moments with her son the mother would say, “This is not who you are. You are a kind, strong, caring young man, who will grow up to be a defender of the weak.” This was a powerful narrative the mother was giving her son, one that allowed him to conceptualize his behavior in such a way that he knew it was wrong, but not representative of who he was. Instead, it gave him a sense of who he could be.

After an especially bad week marked by multiple setbacks, I took a moment with the mother to share with her the story she had told me. “I see a strong mother, who despite her circumstances, is relentlessly committed to her son. I see a mother who believes the best in her son; whose every action slowly pours goodness and kindness into him. And one day, all that hard work will pay off. With each investment of time and love, your son will grow to be a kind and caring man before your very eyes.” As I shared this story with her, I could see her eyes well up. She said, “Thank you.”

After our professional relationship ended and several years had passed, I bumped into her at a coffee shop. Doing my best to protect her confidentiality, I proceeded to order my coffee and not disturb her. Having apparently seen me, she stopped me and shared that her son was an entirely different person than the young boy I knew. He was doing better in school, no longer violent, and treated her with respect and kindness. To say I was shocked would be an understatement. This case was one that always stood out in my memory. When working with them, I had very little hope that the young man would come around.

***

Many factors played an important role in the young man’s journey. But from my perspective, a great deal of importance should be attributed to his mother’s strength-based, life-giving, love-fueled narrative that she willed into existence. I also believe that the affirming and hopeful narrative sustained her just as much as it did him. The kinds of stories clients construct and tell about themselves shape the kinds of lives they live. The journey of the mother, her son, and myself are living proof of that.

Confusion of Tongues

Confusion of Tongues

I’m not surprised when I get an email from Lara, who was my patient nineteen years ago. Lara was only ten years old when her parents suddenly ended her treatment and moved the family to the West Coast. In the years since, I have thought about her often, remembering her unusual story, wondering how she is doing. When I see her name in my inbox it is almost as if I am expecting it.

“I’m writing to see if we could meet,” Lara writes. “I’m twenty-nine years old now and there is so much I would like to talk to you about. Do you even remember me?”

It is hard not to remember Lara. She was one of my first child patients when I opened my private practice in New York City. I saw her for two years and often felt uneasy thinking about her unresolved family situation, which I have revisited in my head over all these years.

Lara’s was one of the most confusing cases of sexual abuse that I have treated, and as time passed and I studied the nature of the intergenerational aspect of sexual abuse, I felt that I was able to make better sense of it. Maybe it was my ongoing desire to share those thoughts with Lara that made me hope that she would contact me.

I was researching the topic of sexual abuse in childhood when I started seeing Lara.

Beatrice Beebe, one of my mentors and an infant researcher at Columbia University, is known for saying “Research is me-search.” By that she means that all psychological research, even when we are not aware of it, is our quest to understand and heal ourselves and the people who raised us.

Starting this research, I was not sure what I was looking for. What was it that I really needed to know about myself and about the world around me? What was my “me-search”?

That is the question I have asked every student I have mentored since, with the genuine belief that deep inside we continuously try to resolve the mysteries of our own minds. Feelings are always the motivations for intellectual investigations, even as we rationalize the world around us. I started my research interested in what the Hungarian psychoanalyst Sándor Ferenczi called “the confusion of tongues.” Borrowing from the biblical story of the Tower of Babel, Ferenczi refers to the confusion between the language of tenderness that children speak and the language of passion that abusers introduce.

The paradox of affection and exploitation is one of the most prevalent confusions related to sexual abuse, one that leaves children bewildered and tormented. Abusers don’t just threaten and scare children; they often provide affection, promise security, and make the child feel special. I focused my research on what children’s play could teach us about their emotional experiences and vulnerabilities, and I was particularly interested in documenting the playing out with children of fairy tales, stories that contain emotional material that carries universal meaning. I chose one fairy tale to research with my young patients: “Little Red Riding Hood.”

About a week after my research proposal was approved, Lara walked into my office. She opened the session by saying, “Today I have an idea of what we could do.”

She and I usually played “family” together. She would ask me to play the daughter so she could be the mother, and through that role-play I not only learned but also felt how painful it was to be a daughter in her family. Playing a daughter who, like herself, lived with her parents, Hanna and Jed, and with her half brother, Ethan, who was nine years older, allowed me to know what no one could tell me in words: that they were all confused and scared and that Lara was holding a family secret for all of them.

“What is your idea?” I asked, and Lara surprised me with the answer: “Can we play Red Riding Hood together?”

I was stunned by the coincidence. How did she know that this was the fairy tale I had chosen for my research and that I had gotten the approval to start only the week before?

The more experience I have with patients, the more I learn how unconsciously connected we are to the people around us. With Lara, it was the first time I’d experienced that, but it wouldn’t be the last. Since then I have had many uncanny coincidences with my patients. Through our dreams, reveries, and synchronicities we realize that we know more about one another than we are aware of.

Lara smiled. “You are the daughter and I am the mother,” she said.

I opened the closet. There were the new puppets I had just gotten: a girl with a red dress, a mother, a grandmother, and a wolf.

“What about the grandmother and the wolf?” I asked. “Who plays them?”

Lara paused. “We don’t need a wolf,” she said. “There are no wolves in our story.”

A few weeks before my first session with Lara, I had met with her parents, Hanna and Jed.

When working with children I always meet first with the parents, to gather information about the child and the family and to discuss the goals and process of therapy. Although the child is the one in therapy, very often it is the parents who need the most help. Children frequently express the reality of the family and become what we call the “identified patient,” which means the one who seems like the “sick” member of the family. Those children usually carry and express the problems of the whole family as a unit. Most families have one member who is unconsciously assigned to carry the symptoms, that is, the family member on whom the family projects the pathology. That person, often one of the children, will be the one sent to therapy. When treating families as a system, we explore the role of the child as the symptom carrier for the family.

Lara was the “identified patient” in her family. She was in second grade and would wake up in the mornings nauseous, holding her stomach and crying that she didn’t want to go to school. Her parents believed she suffered from social anxiety. After meeting with Lara, I understood her anxiety a little differently, realizing that she was worried about her mother, and therefore it was hard for her to separate from her. It wasn’t that Lara didn’t want to go to school, but rather that she wanted to stay home with Hanna, whom she experienced as distressed and felt she needed to protect.

A Frightening and Unusual Story

During that first session, Hanna and Jed told me an unusual and frightening story. They explained that when Lara was only five years old, her grandmother, Hanna’s mother, Masha, filed a complaint against Ethan, Jed’s son from his first marriage, for molesting Lara. Ethan was fourteen years old then, and social services were called to the house to investigate. But no signs of sexual abuse were found and the file was closed. Since then, Masha had filed eight more complaints against Ethan. Each time there was an investigation but no evidence was found and no charges were filed.

“Our family is torn. We don’t know what to do and whom to believe,” Hanna told me during that first session. “I haven’t slept well since it happened.”

Jed looked at Hanna and told me that Hanna was the one who had raised Ethan. Jed’s first wife had died when Ethan was only seven years old, and when Hanna had married Jed, she had become a mother to his son. Hanna loved Ethan.

“Since her mother accused Ethan of molesting Lara, everything in our family has changed,” Jed said. “We all became suspicious of one another, not sure who lies and whom to believe, whom we need to protect and whom to blame.”

Hanna started to cry. “I don’t believe he did it,” she said. “I really don’t believe it. I know him so well and I know my mother; when it comes to these things she can be a little crazy.”

“What are ‘these things’?” I asked.

Jed reached out and held Hanna’s hand. She didn’t answer.

“This situation has created a lot of tension between us,” he said. “Hanna became depressed. She blames herself.”

“What are you blaming yourself for?” I asked.

“I’m her mother,” Hanna said, sobbing. “I’m the one who should know what the truth is.” She grabbed a tissue from the box and looked at me. “I don’t know, maybe I’m wrong and my mother is right and something terrible happened right in front of my eyes. I don’t know how to protect my daughter.”

There was a long silence and then Hanna said, “I realize that maybe it’s my mother that I should protect my daughter from. My own mother, whom I love. But why would she blame him? Why would she do that?”

Hanna and Jed hoped that someone would tell them what had really happened. They yearned for the truth.

“What does Lara know about this situation? Is she aware of anything?” I asked before we ended the session.

Jed looked at Hanna and they were both silent for a long minute.

“About a year ago, my mother came to visit and told Lara that Ethan had sexually abused her.” Hanna sighed.

“She told Lara that all those years she had been trying to help her, ‘to scream her scream’ she called it. But that no one listened to her. She told her that she should never be alone with Ethan.”

Jed nodded. “From then on, Lara didn’t want to go to school anymore. We thought she had become afraid of people and that’s why we decided to bring her to therapy.” The first session ended and my head was spinning. I felt nauseous and realized that those were exactly the symptoms Lara’s parents described Lara as having. I was curious to meet her.

The next day Lara arrived at her first session accompanied by Jed. She held her father’s hand, her long black hair tied in a ponytail, and didn’t look at me. “I like your office,” she said quietly, looking around, a shy smile on her face. I liked Lara from the first moment. In that initial session, Lara told me about her family and described nonchalantly how Ethan was accused of touching her inappropriately.

“My grandmother doesn’t like my brother,” she said. “Maybe she even hates him and she wants him to go to jail.”

Lara talked about these facts without emotion, as if none of this was about her. She turned to look at the dolls in the corner of the room and asked if she could play with them.

For a year, during every session we played while we talked. I observed the play and tried to listen to what she was teaching me about her world, her emotional experience, and her vulnerabilities.

Since it was not clear whether Lara had in fact been sexually abused, I decided not to include her in my research. It was surprising then when she suggested that we play Little Red Riding Hood. “It’s my favorite fairy tale.” She smiled. “Except there are no wolves in our story, remember?”

Years before it was adapted by the Grimm Brothers, “Little Red Riding Hood” made its debut in a version written by Charles Perrault in 1697. Perrault’s story was adapted from the folktale, and in it he described the moment the child met the wolf, referred to as “Mister Wolf,” implying that the wolf stood for a human being.

In Perrault’s version, when Little Red Riding Hood arrives at her grandmother’s house, the wolf is lying in bed and asks her to undress and join him. Little Red Riding Hood is alarmed to see his disrobed body and says, “Grandmother, what long arms you have,” to which the wolf replies, “The better to hug you with.” Perrault’s version ends with the wolf devouring Little Red Riding Hood, followed by a short poem that teaches the moral of the story: that good girls should be cautious when approached by men. As for wolves, he adds, these take on many different forms, and the nice ones are the most dangerous of all, especially those who follow young girls in the streets and into their homes.

Perrault presented his readers with a somewhat refined version of the popular folktale, which was originally filled with sexual seduction, rape, and murder. His version speaks to the deceiving nature of nice wolves, who hurt their victims while pretending to offer something special, presenting sexual perversion as a form of love. It was to become even more highly refined over the years to the point where the sexual innuendo was entirely omitted and the story transformed into a children’s fairy tale.

While fairy tales usually differentiate between good and bad people in ways that help children organize their world and feel safe, “nice wolves” leave children confused, unsure of what is dangerous and what is not. Abused children end up feeling that they themselves are bad, that they have done something wrong. That confusion of tongues between love and perversion will haunt them for years.

“You are Little Red Riding Hood,” Lara says, and hands me the puppet of the girl with the red dress.

“She is going to visit her grandmother,” she says and then whispers, “The girl thinks the grandmother is an old lady but she is actually a wolf.”

“A wolf?” I repeat her words and remember how she kept stating there were to be no wolves in our story.

“You will see.” She smiles as if hiding something. “You will see what I mean soon. The grandmother has a lot of secrets.”

But we don’t find out what the grandmother’s secrets are, nor do we ever get to her house. Instead Lara instructs me, as Red Riding Hood, to sit under a tree and wait for her to come pick me up.

“I will be back soon,” she says firmly.

She turns her back to me and starts playing on her own. I am left to sit there for a long while, knowing that I have been assigned to be the girl that Lara has been, lost alone in the woods, overwhelmed by the secrets of others. Sitting there in silence, waiting for Lara to come back, I feel like the little girl I used to be, when I was left to wait for my parents to come pick me up from the candy store. My “me-search” enters the room and I realize what I am looking for. I suddenly remember what I always knew.

I was seven years old, younger than Lara. I had started second grade in a new school far from our home. During the first week of school my parents had told me that we were planning to move to a new apartment, closer to the new school, but until then I should wait at the candy store after school and they would pick me up from there.

Every day, I walked to the candy store on the corner and waited, exactly as they’d told me to do. Moses, the owner of the store, was a kindly old man with a white mustache and a big smile. I liked him. I believed that he liked me too, and I especially liked that he gave me candy.

As a little girl, there was nothing I loved more than candy. My mother, in an attempt to feed us healthy food, did not allow it in the house. She used to serve us plates with sliced apples and dried fruit. “Candy made by nature,” she called it.

When Moses offered me candy for the first time, I was thrilled and ate it as fast as I could. He looked at me and smiled. “I see that you really love it.”

The following day he offered me ice cream that he kept in a freezer in the back of the store. “What kind do you like?” He had a cone in each hand. “Vanilla or chocolate?”

I pointed to the vanilla one.

“Why did I know you would choose that one?” he teased, and then asked if I wanted to come pick out something from the back of the store.

“I will let you choose whatever you like,” he said.

Moses always smiled, and his kisses were ticklish and wet. Once in a while his wife would come to the store and he would put a little chair for me in the front and ignore me until she left.

When my dad arrived to pick me up, Moses would tell him what a good girl I was and wave goodbye. “See you tomorrow.”

I liked waiting for my parents there, but as time passed I started feeling nauseous.

“Moses gives you too much candy,” my mother would say. “That’s why your stomach hurts.”

But that wasn’t the reason. I wasn’t sure why; I just knew that I didn’t like it when he hugged me so tight. I still liked him even when I didn’t.

In third grade I stopped liking Moses. We moved to our new home and I tried to avoid walking near his store. Only years later was I able to put it all together and understand what had really happened in the first few months of second grade. I never told anyone, and I wasn’t always sure if it had actually happened or if I’d imagined it.

Freud viewed memory as a fluid entity that was constantly changing and being reworked over time. He referred to this dynamic as nachträglichkeit, translated into English as “afterwardness,” which means that early traumatic events are layered with new meanings throughout life. Freud was especially focused on sexual abuse as an event that would be reworked retrospectively as the child got older and reached certain developmental phases. Sexual abuse in childhood isn’t always registered by the child as traumatic. The child is overwhelmed with something they cannot process or even make sense of.

As time passes, the traumatic experience is reprocessed. In every developmental phase the child will revisit the abuse from a different angle and with different understanding. When that abused child becomes a teenager and then an adult, when they have sex for the first time or have children, when their child reaches the age they were when the abuse happened — in each moment the abuse will be reprocessed from a slightly different perspective. The process of mourning keeps changing and accrues new layers of meaning. Time will not necessarily make the memory fade; instead, the memory will appear and reappear in different forms and will be experienced simultaneously as real and unreal.

Nineteen years after I first met Lara, it is a gloomy day in mid-September and I’m about to meet her again. It is also my birthday. In the intervening years, I’ve had three children. I have stopped working with children and am now only seeing adults. My office is in the same neighborhood as it was nineteen years ago, in downtown Manhattan.

I open my door and look at the tall young woman who stands there. I do not recognize her.

“I grew up quite a bit.” She smiles as if reading my mind. “Thank you for answering my email so quickly, and for agreeing to see me.”

She sits on the couch and looks around. “I like your new office.”

I recognize her smile and these first words.

“Those were your exact words when I met you for the first time,” I say, trying to learn something about her from the way she looks: the black T-shirt, the black long silk skirt, her sneakers and blue nail polish, and her long straight hair, which I think used to be curly. I’m trying to read what has happened to her in the years since then. Where has she been? Is she happy? Did she find out what really happened?

“I know it’s your birthday today,” she then says to my surprise.

I nod and smile. Some things don’t change. She still knows more about me than I expect.

“Don’t worry, I can’t read your mind,” she adds as if reading my mind. “When I tried to find you, I googled you, and one of the first things I found on your Wikipedia page was your birthday. I was happy you scheduled our session for today. I really wanted to give you a gift.”

Traditionally, therapists do not accept gifts from patients. The contract with our patients is clear; there is no dual relationship, no exchanges other than our professional services for an hourly fee. Psychoanalyst and patient share a joint goal of trying to explore the unconscious; therefore, it’s interesting to understand when and why a patient brings a gift and what that gift represents. But in reality nothing can make a gift feel unappreciated and dismissed more than analyzing it.

Lara opens her bag and hands me a small puppet. It is a girl wearing a red dress. Our Little Red Riding Hood.

She surprises me again.

“Do you remember?” she asks, and she suddenly sounds like the little girl she used to be.

“Of course I do. I never forgot,” I say.

We look at each other. I like her as much as I did all those years ago, and I wonder what has made her look for me now.

“I came to see you because I need your help.” She answers the question I haven’t yet asked out loud.

We start where we stopped years before. Lara tells me about her family’s move back then to the West Coast. It was sudden; she didn’t even have a chance to say goodbye. “In retrospect maybe we were running away,” she says. “Running away from the unhappiness my family lived in. But the unhappiness followed us and in fact only got worse.” The tension between Lara’s parents, Hanna and Jed, became intolerable, and four years later, they got divorced. Jed lost his job and had to move to work in Denver. Hanna grew even more depressed and was hospitalized. Lara found herself alone, and at the age of fourteen she had to move yet again, this time to live with her grandmother Masha.

Lara talks and I feel sad and worried. How was it for her to move again, to separate from both her parents? To live with her grandmother, whom she used to have mixed feelings about?

“At that point things actually got better,” she continues. “My grandmother was wonderful and my life with her was so much easier. I realized why my mother loved her so much. She supported me and understood how hard this new living situation was for me. She was caring and gave me everything I needed. Once a week we traveled together to visit my mother in the hospital, and once a month we visited my father. At some point, after my mother was discharged, I made the decision to stay and live with my grandmother permanently.”

I listen to Lara and remember the way Hanna used to talk about her mother, defend her, describe how in spite of the fact that she believed her mother was responsible for the break in their family, she loved her and could never fully blame her. When Jed expected Hanna to cut her mother out of their life, she refused. Now Lara expresses the same feelings about her grandmother. Something has changed since her grandmother was our bad wolf.

“My grandmother grew up in Russia with eight siblings,” Lara tells me. “She is the youngest and the only one who is educated. She values education and encouraged me to go to graduate school. In fact, she’ll be paying for my doctoral degree,” Lara says and then smiles shyly. “I decided to study psychology. I was just accepted into a PhD program.” Then she starts giggling. “Maybe I want to be you. I mean, as a child, therapy was the only time I didn’t feel alone. I felt that you really wanted to know me.”

Lara takes a deep breath. She looks tired and I see how hard she tries to be likable, easygoing, not depressed like her mother. She was always tuned in to others, making sure she was not a burden on them and instead taking care of those around her.

“You said you needed my help.” My voice sounds softer than usual as I ask, “Tell me, what brings you here today, Lara?”

Lara stares out the window for a long time.

“Your old office used to have big windows looking at Grace Church, I remember,” she says, still gazing outside. “There was a coffee place across the street and I used to sit there with my father every week after therapy. He would order fresh mint tea and a croissant, and I would get a baguette and use all the chocolate spreads that were on the table. Every week we would sit there silently, eating and not looking at each other. He never asked me how therapy was. Maybe he was too afraid to know. And I didn’t think about anything else but the sweet spreads that my mother didn’t like me to eat and that made the end of a session less bitter. I never liked separations."

“I remember sitting across the street, staring at the entrance of your building, hoping to see you walk out and wave to me. I didn’t want you to meet anyone else after I left. I wanted you just for myself. And I wished that my father would say something, ask me something, it didn’t matter what. Even one question would have been enough, so we wouldn’t have to sit there in silence. I wished that he would wonder out loud if I liked the spreads and which one I liked most. I would point to the hazelnut chocolate, and maybe then I could tell him about Little Red Riding Hood’s basket that we packed just before the end of the session and how I put unhealthy candy in it and nothing else. I wished that he would smile and say that he knew I loved sweets because he noticed that I ordered the spreads after therapy every time. But he didn’t ask anything, and I wasn’t sure that he noticed what I was eating or anything else about me.”


Lara pauses and looks straight into my eyes.

“There are many questions from my childhood that were never asked. There was no grown-up who could know the answers. There is a mystery that I wasn’t able to resolve on my own,” she says, and I know what she is talking about.

Lara and I start meeting again once a week. She begins her doctoral program, trying to find the topic for her dissertation, her “me-search.” Her mind will lead us to the questions that were never asked. Her research question will be born in that void and so will the truth.

It is a winter day when Lara comes in holding an old picture; in it she is thirteen years old, with a backpack on her shoulders. She is wearing gym clothes and is smiling at the camera.

“This is from the time before my parents got divorced,” she says, and I recognize the girl in the picture; she looks very much like the girl I knew. “I will never forget that day; it’s when I got my period for the first time. My mother took this picture and then called my grandmother to tell her that the ‘aunt was visiting’ or something funny like that.” She pauses.

“I heard them fighting for the first time. My mother was crying and yelling at my grandmother. I couldn’t hear what my grandmother was saying but I knew it was bad. I knew she made my mother very upset and I felt terrible. I thought it was all because of me.

“It was the one time I remember asking directly: ‘Mom, what happened?’ “‘It’s nothing; it’s between me and Grandma,’ my mother said, but I didn’t give up. ‘What did she say? Why are you crying?’”

Hanna told Lara that her mother had asked her to cut Lara’s hair short.

“My mother told me that and started crying again. She thought it was the meanest thing one could do to a girl. She thought it was crazy.

She told me that when she was about my age and got her period for the first time, my grandmother took her to the barber and without further explanation had her hair cut short. She remembered looking in the mirror and the tears running down her cheeks. ‘I look like a boy,’ she sobbed.

“‘Why did she do that?’ I asked, but my mother didn’t answer. I asked again, ‘Mom, why did Grandma do that to you when you were my age?’

“‘Sometimes it’s hard to understand Grandma,’ my mother answered. ‘She brought strange traditions from her country, from her own childhood, who knows.’”

Lara and I are silent. I wonder if she has the same thought I have. Does she realize that her grandmother was trying to protect her daughter by making her look like a boy and not a girl? Did she try to protect her daughter, and now her granddaughter, from sexual abuse?

No one wanted to know. No one ever asked.

I remain silent, asking myself if Lara is ready to question her family history.

Our wish to know everything about our parents is a myth. Children are in fact often ambivalent about learning too much about their parents. They don’t want to know about their parents’ sexuality and often try to avoid knowing intimate things from their history.

“I need to know what really happened,” Lara says decisively and points her finger at the girl in the picture.

The girl in the picture smiles a fake smile.

“My grandmother,” she says, touching her long straight hair, “was always so protective of me. She accused Ethan of abusing me, but then after my parents got divorced that was all forgotten. No one talked about it anymore. That was strange.”

Lara looks severe. She suddenly seems much older than her twenty-nine years. She takes a brief glimpse at her watch, calculating how long we have until the end of the session. I know she needs time to think through her history.

“When I lived with my grandmother she used to scare me,” she says. “She used to repeat that I had to be careful. She would tell me strange things, for instance, that I needed to wear underwear to bed, other- worms would get into my vagina. She would whisper it and I remember feeling nauseous. Every time she talked about my body she would start whispering. When it came to sex her boundaries were strange. She talked about inappropriate things as if they were normal and about normal things as if they were perverse. Her whispering made me feel dirty, as if she had dark secrets that came out at night, and then in the morning she would be my loving grandmother again.”

“When you were ten years old and we played Little Red Riding Hood, you told me that the grandmother in the story had a lot of secrets,” I say. ‘You will see,’ you used to repeat, ‘you will see.’ But we never found out what those secrets were. Maybe you are ready now to ask the questions that were never asked.”

Lara travels to meet with her grandmother Masha. She wants to learn about Masha’s childhood and hopes to find her own answers there.

Masha grew up in a chaotic household with very few resources. Her parents went to work early in the morning and came back late at night. Her oldest sister, who was thirteen, became her main caretaker. Masha told Lara that she always felt her mother didn’t want her, that deep inside, her mother regretted having so many children. Masha was a shy girl and a good student. Excelling at school was her way to feel special and worthy.

One night, when Masha was ten years old, she had a bad dream. She often had bad dreams but knew she couldn’t wake her parents up or they would be upset with her. She sneaked into her fifteen-year-old brother’s bed. Her brother was the smartest; he was funny and brave and the one she admired the most.

He kissed her.

From then on her brother came into her bed every few nights. She would make believe she was asleep and wouldn’t make any noise. He would touch her gently and never hurt her. In the morning they behaved as if nothing had happened.

It was when Masha was about thirteen and got her period for the first time that her mother told her in a very matter-of-fact way that she shouldn’t let her brother in her bed anymore.

“Do you mean her mother knew?” I can’t stop myself as I interrupt Lara, who is still shaken by what she learned.

Lara nods. “Yes, but they never talked about it. She never told anyone.”

Unprocessed experiences always find ways to come back to life, to reenact themselves again and again. Masha’s repressed memory came to life in the typical way repressed memories do. It snuck into the mind unexpectedly, triggered by later events. For Masha, Ethan and Lara were a reminder of her and her older brother. That close relationship between a brother and a sister awakened her own repressed memory, and she felt the urge to give Lara the protection she never had, to be the parent she herself had always wanted. Her request that Lara’s hair be cut short was an attempt to protect Lara, in the same way that Masha believed she protected her daughter, Hanna, when she became a woman. Through Lara, Masha relived her own sexual abuse, which she could never fully process.

Sexual abuse is one of the most confusing traumatic experiences that we know. The intergenerational aspect of sexual abuse is unique in the way that each generation overwhelms the next and inflicts on it the drama of their sexual trauma.

The next generation’s world is often sexualized in the same way that the victim was sexualized as a child. They feel flooded by the parent’s unintegrated sexuality and perplexing boundaries. As Lara describes, innocent, trivial things, such as the underwear she wore when she went to sleep, were filled with sexual meanings. The adult — in this case Lara’s grandmother — who tries to make sense of her own feelings often communicates to the child the confusion about what is safe and what isn’t. The original confusion between innocence and perversion is played out through the next generation, with seduction, promiscuity, and prohibition all intermingled. The next generation usually describes growing up with a constant, vague feeling of violation that only later in therapy is understood to be related to the original break of boundaries in their family’s history of sexual abuse.

In her article “Enduring Mothers, Enduring Knowledge: On Rape and History,” Dr. Judith Alpert describes how sexual abuse can present itself in the mind of the next generation. Using her own childhood experience, she discusses the way traumatic thoughts and “memories” can be transmitted from parents and grandparents and present themselves in the child’s mind as their own. That phenomenon leaves everyone, the child and her caretakers, with the confusion that is at the core of sexual abuse. As in Lara’s case, our challenge is to hold all generations in mind — grandmother, mother, and child — as victims of either sexual abuse or the intergenerational inheritance of sexual abuse.

Masha, who was reliving her own unprocessed trauma, devastated her family with the idea that Lara’s brother sexually abused her. Lara became more and more overwhelmed. It was as if she were reliving her grandmother’s repressed feelings. Through the family’s ongoing rumination and the premature introduction of sex, Lara felt the intrusion into her body and thus the scene of sexual abuse was reenacted.

“When I was sitting with my grandmother last week and she told me about her childhood, I cried. She didn’t,” Lara says, and tears drop down her cheeks. “I tried to listen to her the way you listen to me, and to help her understand that she could tell me anything and I wouldn’t judge her, that I really wanted to know her.

“At some point she stopped and said she didn’t want to talk about it anymore. But she kept talking and I didn’t say a word. She started blaming herself, saying it was she who went into his bed first. Then she started to question her memory and said that it all sounded much worse than it actually was, that things were different then.

“Before we went to sleep she made me a cup of tea and served it with a slice of the chocolate cake she had baked for me.

“‘I know how much you like chocolate,’ my grandmother said, and hugged me. Then she held my shoulders, making sure I looked at her. ‘Lara, please don’t take my problems on you,’ she said. ‘I don’t want you to be sad because bad things happened to me. Worse things happen to people. That’s life; my life isn’t so special.’

“‘You had to keep a secret for so many years, Grandma,’ I said, and hugged her as tight as I could. But she just kept nodding. ‘I didn’t keep a secret. It was something I didn’t always remember. The secret kept itself.’”

“I think I found my ‘me-search,’” Lara tells me as she wipes her tears.

       ***

She will go on to study the tormenting and deceptive impact of incest and sexual abuse on the next generation, those aspects that are hard to research, as they are seemingly irrational, puzzling, and unformulated experiences, but that Lara lived through in her own childhood. We both recognize that one way to face that transmission from generation to generation is to process those experiences and help others process and own them, too. Demons tend to vanish when we turn on the lights.

A Path Towards Self-Compassion and Healing

Foundations of Relationship

To be in an intimate and interdependent relationship with another person is one of the most challenging endeavors in life, which is why conflict in relationships is one of the major reasons many come to me for therapy.

Clients often reach out to me because they are in pain and struggling with a significant relationship break-up. It is particularly difficult for my clients to be in a close relationship with others if they do not have a conscious relationship to their own self. Thus, an important task in therapy is to identify what it means for them to first be in an intimate relationship with themselves. This may include learning how to sit with their feelings of emptiness, being present with their bodily sensations and emotions, and examining their past. Therapy can be challenging, but it also offers clients the opportunity to heal wounds and to reclaim the forgotten and disconnected parts of themselves that may be unconsciously re-enacted in current relationships.

Many women come into my office suffering with low self-esteem, depression, and anxiety. They feel isolated, alone, and long for a sense of purpose in their lives. They long for connection and believe that closeness with another will help them feel complete, that being in love will alleviate their emotional pain. Close contact with others in reciprocal and enduring relationships is both a biological and psychological need, which increases their urgency to be in close partnerships with others.

Many of the relationship problems I work with are fueled by the belief that another person can fill their emptiness and replace the pain with feelings of love and passion. However, as my very wise mother once said, “we fall in love to the same degree that we are lonely,” fall being the operative word. In this context, if a client falls in love out of distress, to fill a void or erase the emptiness, there is a good chance it will lead to more distress. Family therapist John Fogarty asserts that our emptiness and pain are related to our relationship to our most distant parent. If that is accurate, then healing comes when we can help clients reclaim the hurt child of the past and repair their wounds there. If not, they are at risk of getting trapped in the past and replaying their early stories in adult relationships. To help ensure that dysfunctional patterns of the past do not get re-enacted, unlocking and facing the past becomes an important goal in therapy.

The Case of Alana

Alana was referred to me by a clinician from an inpatient substance abuse program who had diagnosed her with Post-Traumatic Stress Disorder (PTSD) and a severe Cannabis Use Disorder. Her clinician explained to me that since Alana entered the program and stopped using marijuana, she had become flooded with horrific memories of child abuse. The referring therapist was concerned that Alana would be at risk of relapse if her PTSD symptoms, which included flashbacks, were not addressed. I have found that it is not uncommon for people to turn to the use of substances to manage their PTSD symptoms of flashbacks and hypervigilance.

When Alana walked into my office for our very first session, her fragility was immediately apparent. She was small in stature, five-feet tall and thin. Her head was down, her shoulders drooped, and she did not make eye contact. She talked softly, almost inaudibly, and had long pauses between sentences. She was easily startled, and when she heard the door in the waiting room close, she jumped, and her body tightened. This was certainly a shaky start for this fragile and uncertain woman.

A year into treatment, Alana entered one particular session smiling and happy. She had had a lunch date with someone she had met through a friend. During lunch they discovered they had a number of commonalities: they both loved animals and had dogs, they loved to hike and travel, they were both teachers and enjoyed working with young children. At the end of lunch, they exchanged numbers and he “promised” he would be in touch. Alana was happy, and I was happy for her. She had worked hard in therapy and was gaining a stable foundation in her life without the use of substances. I interpreted her desire to reach out and make a connection with another person as a sign that she was moving forward in her recovery. Four days after this particular session, I received a call from Alana who asked for an “emergency session” because, in her words, “I am not doing well.” During the session, Alana was shaking and could not stop crying. She said she felt she was going down a dark abyss and was fearful she would never return. She had reached out to me because she was desperately trying not to “spiral out of control.” She was afraid she was going crazy. Contacting me for that emergency session was her attempt to anchor and ground herself. Alana explained the trigger that brought her into the emergency session was that Michael, the man with whom she had been on a lunch date, had “promised” he would be in touch with her but she had not heard from him. In the four days since they had lunch, Alana texted him and tried calling him a number of times, but he was not responding. She drove to his house to check if his car was there and if he was home. The lack of contact with Michael was bewildering, and Alana began to doubt if the positive feelings she experienced during lunch were “one way” and “all in my head.”

Alana’s levels of fear and anxiety were high. In general, I have found that when a client’s feelings are exaggerated and seemingly out of proportion to the current situation, it is a signal that their emotional response has roots in unresolved experiences from the past. When these clients are in a highly emotional, reactive, and anxious state, a rational response actually raises their level of apprehension and serves to exacerbate the client’s sense of disconnection from the therapist. With this in mind, I asked Alana if she was willing to slow down, breathe more deeply, and focus her awareness inward on her body. We had done similar exercises in the past, and Alana was not new to this type of therapeutic inquiry. However, familiarity does not always make this journey any less challenging. It takes courage to sit with and explore the bodily sensations and feelings that are experienced as overwhelming.

I was aware of Alana’s abuse history and her terror associated with feeling abandoned and alone. As a result, I used phrases like “You are not alone—we can take a look at this together.” I could see she found these words soothing and the words helped her to self-regulate. Her face relaxed, her breathing became easier, and her words and the quality of her voice softened. The following is a segment from the session (C represents client and T represents therapist):

T: Is it okay to take a few moments to breathe and go into your body?
C: Yes.
T: What part of your body wants to talk now?
C: My stomach and throat.
T: How do you know your stomach and your throat want to talk?
C: My stomach and throat feel tight.
T: Anything else?
C: My stomach feels tight, like it wants to throw up, and my throat feels like it is hot and on fire.
T: Your stomach feels tight like it wants to throw up, and your throat feels tight like it is hot on fire—anything else?
C: No.
T: Which do you want to take a look at first—your stomach or your throat?
C: Stomach.
T: Is it okay to stay with the sensations in your stomach?
C: Yes.
T: Your stomach is tight and wants to throw up. If you could give it a feeling, what would the feeling be?
C: I don’t know.
T: Breathe… What would tight and wanting to throw up be—mad, sad, glad, or scared? Breathe into the tightness in your stomach, just for a moment. Can you give the tightness in your stomach permission to relax? Then it can tighten up again.
C: It feels scary.
T: Can you stay with scary?
C: Yes—I am alone, and it’s dark.
T: Is it okay to give room for scared and alone in the dark?
C: [With eyes closed she nods yes]
T: Breathe… I am right here with you. What might happen if you let yourself feel scared and alone in the dark?
C: I would disappear and never come back.
T: What would happen if you disappeared and never came back? Breathe and stay with the tightness in the stomach.
C: I would never be able to find my way out of the darkness.
T: What would happen if you could not find your way out of the darkness?
C: I would disappear and be lost forever—I would not know how to find my way back.
T: Can we go into the nausea?
C: [Nods. After a few moments] The tightness and nausea help keep me in my body.
T: So the tightness and the nausea in your stomach protects you and keeps you connected to your body so you do not get lost in the darkness?
C: Yes.
T: Is it okay if we go to the sensations in your throat?
C: Yes—It is tight and hot like it’s on fire.
T: If tight and hot like it's on fire could talk, what would it say?
C: There are no words—just a sound.
T: What sound would it make?
C: A long, wailing cry.
T: Can we stay there?
C: Yes—the wailing cry is the sound of all the fear and pain in my stomach.

Alana started to sob. She was finally able to put words to her visceral experience which, until this moment, was out of her awareness. As the session continued, Alana was able to explore the childhood event that was fueling her current experience with Michael.

C: For as long as I can remember, my father would beat me and pushed away my attempts to get close to him.
T: When was the first time you can remember being pushed away from your father when trying to get close to him?
C: I can remember when I was three or four years old and my father was sitting in the living room chair watching television, sipping on what I know now was a glass of scotch. I was staring at him from across the room. I knew I needed to be quiet and almost invisible so as not to get him upset. While sitting on the floor, I slowly and quietly moved closer and closer in proximity to where he was sitting. I just wanted to be near him and hear him breathing. I wanted some kind of connection. When I finally got close to him, he stood up from the chair, and without a word he kicked me and I curled up in pain. I could hear the door slam behind him as he left our apartment.

Alana was able to stay with the bodily sensations that eventually led her to this memory. As the session continued, Alana made the link between her past and the pain and fear she felt when Michael did not contact her. Over time, Alana came to understand that her relentless and arduous pursuit to contact Michael served as a protective function—to avoid the pain associated with the memory of her father’s abuse. Michael’s lack of contact triggered the despair that she struggled with in dealing with her most distant parent—her detached, angry, cold, and physically abusive father. Alana had spoken about this emptiness and pain in previous sessions. She was keenly aware that her substance use that began at the age of 11 was a way to soothe the pain of rejection and abuse from her father. At these crossroads, when the present felt like the past, Alana was at risk of relapsing and resorting to past mechanisms to self-soothe. For Alana, this included drinking alcohol and using substances.

In later sessions, Alana named this trigger as “wanting connection and being kicked by my father.” Naming the trigger allowed Alana to achieve awareness and take control of her emotions and behaviors when she perceived a disengagement from others. The awareness allowed her the space and time she needed to self-regulate, re-evaluate, and think of more appropriate and rational responses to perceived rejection.

When Alana finally heard from Michael, he explained that he had not been in contact because his father had a heart attack and Michael was called home to be with family. Michael also explained to Alana that he did not think this was a good time for him to begin a relationship, because his free time would be spent with his parents during his father’s recovery. I also assumed that Michael was overwhelmed by Alana’s frantic attempts to get in touch with him. Alana’s desperation had its origins in her early life experiences. Michael became an object of Alana’s distress, which was manifested in the barrage of compulsive texts and phone messages. This objectification contributed to the rupture in their relationship—a rupture that occurred soon after meeting one another, when the lack of a strong relational history did not promote efforts towards a possible repair.

As with most of my clients who experience trauma-related distress, Alana expressed a desire for a secure, comforting, and safe relationship. Despite this desire, Alana’s connections with others could be depicted as highly dysregulated, frantic, and fraught with friction and misunderstanding. Many of the women I have worked with who have histories of trauma are more likely to undergo autonomic nervous system (ANS) responses of fight/flight and/or shutdown/collapse. These physiological states are mechanisms that assisted them in surviving overwhelming physical and/or emotional experiences. However, over a long period of time, after the threat passed, these states no longer served a protective function. Instead, fight created more animosity, flight kept them running in fear, and collapse didn’t allow them energy to live life fully. Eventually, these protective states interfered with their ability to think clearly and make thoughtful decisions. In Alana’s situation, the lack of response from Michael put her in a hyper-aroused state, causing her to be vigilant and unable to maintain calm, think about consequences, and come up with alternative solutions. From this hyper-aroused position, Alana misinterpreted Michael’s distance as rejection and responded with a high degree of emotional intensity and pursuit behaviors. Her attempts to restore the connection was her misguided approach of trying to soothe the feelings of terror associated with being kicked and rejected by her father. Alana believed (just as her three-year old self had) that her only relief from the pain and emptiness was through reconnecting with Michael.

My goal with Alana and clients with similar challenges is to bring the unconscious to conscious awareness by remembering and examining the early experiences and emotions that fuel their current reenactments. One method I have used in many cases is exploration of core beliefs, which creates a psychic prism from which all experiences and relationships are perceived. In therapy, I explore core beliefs with my clients, the feelings attached to each belief, the origins of the belief, and how the belief and feelings are exhibited in present-day behaviors and one’s worldview. Beliefs often include, but are not limited, to such thoughts as “I am defective,” “unlovable,” “a misfit,” “alone,” or “a failure.” The associated feelings are just as varied and include feelings of grief, sadness, loneliness, shame, anger, and fear. If an individual’s core beliefs and the source of those beliefs remain out of awareness, then the person is at risk of reenacting the past in the present, always with the hope of a different and more affirming outcome. The chronic, painful, and recurring patterns of our lives can be reframed as our younger and fragmented parts of self that are calling out for attention.

The child in all of us hopes to be seen and heard, yearning to be found and reclaimed. This can be framed as a call to bring us back to ourselves. It is in reclaiming our earlier selves that our emancipation and release from the past begins, and that we can start our journey toward rebuilding lives that resonate with our authentic intentions, desires, and values.

Clients with complex and relational traumas share stories of unthinkable acts of abuse that they experienced as children. For many clients, the therapeutic process challenges what they have learned in order to defend, protect, and keep themselves safe and, for some, to stay alive. The therapeutic journey requires the client to expose their vulnerability, fragility, and imperfections. For survivors of trauma, to be vulnerable is equivalent to being weak and at risk for being hurt. Thus, to allow themselves to be vulnerable takes great courage. Courage is the place where they confront fear, anger, sadness and/or shame. However, clients also bring hope—hope that somewhere, in all the confusion, desperation, and negative internal dialogue, life can be different, and that on the other side awaits a better way of being and living in the world. When the client doesn’t have hope, the therapist can hold it for them.

***

The women I interviewed for my book on survivor moms emphatically stated that their relationships to their therapists served as the model they used to develop healthy relationships. The therapist and the therapeutic process taught them how to effectively communicate. In therapy, they learned how to listen, ask questions, talk about feelings, solve problems, tolerate strong emotions, and stay composed when engaging in difficult conversations. Their therapists offered the means to increase feelings of self-worth, enhance self-care, and create a compassionate connection to themselves. This fostered inner confidence and the capacity to develop healthy and intimate relationships with others. Their therapists’ abiding presence offered them an opportunity to sit with, feel, and explore their deepest wounds in a safe and contained relationship. The therapeutic process also afforded the opportunity to become more deeply attuned to themselves and others and enabled an understanding of both the vulnerability and resilience of being human. The knowledge, tools, and wisdom that comes from one’s own healing could then be transferred to the ways they interacted and responded in their relationships with intimate partners, family, friends, and, as importantly, with children—the next generation.

Fellow Therapists: Do You Work With Sex Offenders?

I have had a career-long commitment, or understanding, primarily with myself, but also with insurance companies, that I choose to not work with child-abusers. It is not that I can’t see redemptive possibilities. It is just that I know I have a strong bias and am not willing to forge a pathway to empathy for those who molest children. It is a boundary I set when deciding whom and who not to treat. My thoughts about this dilemma came to the forefront very recently.

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Yesterday, a man who had been on my therapy waiting list finally arrived at my office. On his intake he noted a recent breakup with his girlfriend of several months. He stated he experienced depression and needed help to “get over the relationship.” It was only in session that the rest of his concerns emerged. At the beginning of their relationship, he told her that he had been married and had several children, but lost custody of them in the divorce. At that time, he was in deep financial trouble, having lost his then recently-purchased home, cars, and his wife to her drug addiction. Nevertheless, the Department of Children and Families (DCF) had determined that neither he nor his ex-wife were capable of raising their children, who were subsequently placed into foster care.

The divorce and subsequent foster placement of the children occurred several years prior to my meeting with him. Several of the children had since reached the age of majority. For a seemingly inexplicable reason, the foster parent who later became the adoptive parent of several of the children took it upon herself to contact my client’s girlfriend (I have no idea how she learned about her) in order to warn her that my client had been accused by his then young daughter of inappropriately touching her. True? Not true?

My client vehemently denied that this ever happened and maintains that position to date. According to him, there had been no legal proceedings, and instead, four hours of reported verbal assault by the local police. He was then purportedly presented with paperwork which he signed without reading. Why? As it turned out, he could not read. He only recently discovered that the paperwork was an affirmation of his guilt, precipitating removal of his contact privileges with his children. The most important sentence, that he could not read and was not read to him, was that he was (and possibly still is) forbidden to be around all children under a certain age. He was later told by his ex-wife that he had been placed on the state Registry of Sex Offenders. Boundary alert! But there was something about this man that compelled me to search a bit deeper.

It was easy for me to confirm that he had never been placed on that Registry through a simple request form and a phone call to the state. But what about the other accusations? I suggested he engage an attorney to find out whatever he could from the DCF offices in his state. As stated, he and his wife had been deemed unfit and the children were placed in foster care, from which they were eventually adopted. He has not seen these children since.

If he was and still is a concerned parent, I wondered why would he not have fought this and tried for all these years to see his children? He did admit that one of his older children had recently contacted him and said that the child abuse was a fiction delivered to DCF by his mother, no doubt out of anger and rooted in her addiction. This child, now an adult, refuses to make a legal statement.

As it turns out, DCF initially denied him access to any of the historical paperwork, reportedly stating that it was too late that they could not find electronic versions of it. As the children were no longer “his,” no documents could or would be turned over to him. Nevertheless, his newly-retained attorney persisted and indicated that there was indeed a document my client is not aware of indicating only that in saying goodbye to his children he was “observed hugging his daughter tightly.” This seemed appropriate to me, as he was saying goodbye to her for an indeterminable length of time. As per the attorney’s suggestion, I have not disclosed the existence of the document to my client. There may be more information forthcoming, and while I trust my intuition and am fairly accurate in “reading” my clients, I would be profoundly sad to learn that these accusations of child abuse against this man are true. It will be up to his attorney to share any “new” findings of legal significance. For now, my client is very relieved to know that he is not listed on his state’s offender registry.

Given that he has recently lost another relationship, I believe that my job at this point is to help this man try and understand why that relationship ended and to move forward if possible. His only response in this context thus far is that he just feels more broken. In light of my long-term and deeply-held conviction to not treat child abusers, I question whether I am comfortable treating him. Or, I wonder, am I too far in right now to bow out should more information come forth indicating that the charges of child abuse were indeed valid? As a parent, I intellectually appreciate how the trauma and drama of those events converged in a legal mess for this naïve, then-illiterate man who struggles to date, but am disturbed by his seeming inability or lack of initiative to have fought for custody and have found a way to hold on to his children.

***
 

As a therapist, I have asked myself new questions about how to set professional boundaries as to who I do and do not choose to treat. Do I believe everyone deserves a second chance? No—not when it comes to abusing a child. But this is not a matter of another shot at life. This is partly a story of a man who carries with him the stigma of assuming he was listed as a sex offender in the state for all these years. That was simply not true. A victim of a vicious ex-wife, a potentially inept police team, the inability to read, and the lack of good legal counsel at the time, conspired to trap this man, holding him hostage for wrongs not committed. Had he been found to be an abuser, DCF would have reported him to the state and he would have been on their list. That was never the case. And what about when these boundary lines become blurred? How do I (re)define my role in order to help a client like this one to establish new goals in the center of a complicated and lingering legal morass that may never be resolved? I have decided, at least for now, to continue to meet with him. But what if information does indeed emerge that implicates him? Do I search for redemption or reestablish my professional boundaries? I do not have that answer, at least at this moment in time.
 

That’s Child Abuse

“She can’t come today. I’m actually not really sure where she is.”

Little did I know, this would be the opening line to a new chapter in my nascent counseling career. Every therapist remembers their first child abuse report, and on an overcast day in central Massachusetts, this was about to be mine.

As the phone call continued, I learned that during a particularly heated argument, this mother had struck her daughter, and the teen had run away as a result. Although it was clear to me that mom’s blow to her daughter’s head constituted child abuse, when I consulted with my supervisor, his questioning was along an entirely different line. How long had my client been missing? Had her mother filed a missing person’s report with the police? 

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I informed him that my client had been missing for over two days, and during a second, very awkward phone call, we learned that although she had called the homes of several of her daughter’s friends, my client’s mother had not contacted the police. To my surprise, my supervisor informed me that the mother’s failure to make timely and reasonable efforts to locate her child also constituted child abuse, because being missing put my client at risk of imminent harm.

For new and seasoned clinicians alike, the line between what is and is not legally considered child maltreatment can be difficult to distinguish. Laws vary widely from state to state, and are frequently updated to reflect new findings in abuse and neglect research. The best way to familiarize yourself with your state’s laws is to read the relevant statutes yourself from beginning to end. The U.S. Department of Health and Human Services maintains an excellent search engine through which you can look up your home state’s child maltreatment laws in a matter of seconds.

Although some behaviors clearly constitute child abuse or neglect, other instances of child maltreatment are not as obvious. For example, making believable threats to kill, disfigure, or severely harm a child is considered child abuse in many states, even if the caregiver never acts on them. And many forms of punishment that may not leave physical injuries—such as excessive physical restraint and extended periods of isolation—also fall under legal definitions of child abuse. Additionally, a wide variety of parental inactions are considered child maltreatment, such as failing to establish a significant relationship with a child, failing to seek assistance with school refusal, or engaging in sexual activity with reckless disregard as to whether or not a child is present. Other unconventional forms of child maltreatment include encouraging a child to engage in criminal activity, knowingly exposing a child to sex offenders, and driving under the influence with a child in the car.

The criteria for neglect can also be difficult to navigate, as laws vary significantly from state to state. In some states, a caregiver is not considered neglectful if they are unable to meet their child’s basic needs due to financial inability, unless that caregiver has previously declined public assistance that would have allowed them to meet those needs. In other states, however, a caregiver’s failure to meet a child’s basic needs is considered neglectful regardless of the caregiver’s financial ability to meet those needs.

Similarly, there is wide variation among states in laws related to children’s exposure to illegal drug use. In some states, the issue is not directly addressed in current law, leaving mandated reporters to simply report the emotional or physical injury caused by parental substance abuse. Other states, however, have extensive and detailed legislation on this topic. For example, many states specify that child maltreatment includes knowingly exposing a child to drug paraphernalia, bringing a child to a location where drugs are manufactured, allowing a child to witness a drug sale, placing a child in a vehicle where drugs are being stored, and exposing a child to the materials necessary to manufacture drugs, even if no illicit substances are actually used or manufactured at the time the child is present.

Additionally, increased awareness about abuse to elderly, intellectually disabled, and physically disabled persons has resulted in mandatory reporting laws for these populations in several states. If it has been years since you read your state laws, I encourage you to review them the next time a client no-shows and you find yourself with an unexpected hour. You may be surprised at what has changed!

When in doubt, consult your supervisor and err on the side of caution. It’s always better to report an incident and weather the damage to your therapeutic alliance than to not report one and go home with an uneasy conscience.

In my client’s case, I was surprised at how little changed between her mother and me following my call to the Department of Children and Families. Mom was fully aware that I would be required to report her physical altercation with her daughter, so it made very little difference that her limited attempts to locate her child would also have to be reported. In fact, my call improved my client’s outcomes because being involved with DCF allowed the family to access in-home therapy resources that had been previously unavailable. Although I was terrified of alienating a family in need, reporting this mother’s struggle to discipline her teen turned out to be my most helpful intervention. 

Look at me!

Many people struggle to fully meet their therapist’s eyes the beginning. Particularly those who are shy or introverted.

The warmth, care, interest or love that we may perceive in a therapist’s compassionate gaze may seem “too much” or even unbearable for many who missed or never received it from their original caretakers.

Rachel was my first therapy client totally unable to tolerate the eye contact during a session. The first time we met, this lack of eye contact made me sense her anxiety; she looked like a captured bird, scared and ready to fly away at the first occasion. I thought she would not come back for another session, but she eventually did.

Rachel stuck to the regularity and timing of our sessions, but I kept having an uneasy impression that she was not entirely there. She had been in therapy previously for several years, and her previous therapists had seemed to accept her lack of eye contact without questioning it.

We were doing interesting work, she was open and honest, but my feeling of unease grew. So I decided to address it in the “here and now” with her.

What sense did she make of her avoidance of eye contact?

It helps me to not be really here. At the same time she readily admitted that she wanted to be in therapy and was coming willingly. But to be fully present was “too much.”

To avoid looking into other’s eyes is a very primitive and powerful defense mechanism. For human infants, it is not only a natural way of attracting attention and maintaining it, but also an efficient way of grading the intensity of contact. When we look away and avoid eye contact in a crowded subway train, we expect others to do the same and to not push in, staring at us. When somebody does not respect this tacit message, we may feel invaded, intruded upon in our private space.

Rachel had experienced sexual abuse in her childhood. When our freedom is restricted and we feel trapped (this is what any victim of sexual abuse goes through), the only way we are able to escape, at least partly, the abuser is to close our eyes or to look away. It then becomes the unique way of measuring the quantity of contact, a desperate hope to gain some control over an uncontrollable situation.

I felt compassion for the little girl that had been abused and silenced, but at the same time my frustration with her kept growing. I knew that somehow without confronting this problem our work would get stale.

Talking this through with Rachel helped us put the problem on the table. She was entirely conscious of the impact of her avoidance on our interaction, but still unable to take the risk and meet my eyes.

Look at me! I would I have screamed, had I not been aware of my countertransference.

But with the risk of repeating a traumatic experience, I needed to be patient and “to stay with it.” Her need for security and control was to be respected.

After a while, Rachel felt safe enough to share some painful details of her past. When her abuser, a family member, was with her in the room, she felt too terrified and ashamed to scream. Her parents “were not noticing” what was happening to their young daughter. Years later, when she could finally tell them what had happened, they still chose to ignore the uneasy truth and did not estrange the abuser from the family.

Rachel, a mature adult now, had to face her childhood nightmare, her abuser, at every family gathering. How did she do this?

She learnt to ignore him, to avoid looking at him. This strategy helped again to gain some form of control, an illusion of not entirely being there. Once again, this was the only thing in her power.

With time, I got used to her way of being only half-present, her need to securely preserve some parts of her self. I still enjoyed our dialogue, and the work we were doing around her artistic expression as a cello player.

After a year or so our work came to a natural end. Rachel was doing reasonably well, and she had played successfully at the audition she had initially been so anxious about. As result she landed her dream job in an important orchestra.

At out last session, before saying our goodbyes, Rachel’s eyes briefly met mine. I was now used to this fleeing, light contact between us and appreciated its meaning.

Thank you for not forcing me to make eye contact. When I was abused… he kept saying : “Look at me!” But I never did.

And she gazed at me steadily.

She seemed strong and composed: that looking away had preserved something precious in her; this is how she had defended herself and stood up to the abuser. The new Rachel was able to esteem herself, to fight, to win, and to be a passionate musician.

Bessel van der Kolk on Trauma, Development and Healing

Talking About it Doesn’t Put it Behind You

David Bullard: Bessel, you are the medical director and founder of the Trauma Center at Justice Resource Institute and professor of psychiatry at the Boston University School of Medicine. You have been one of the most influential and outspoken clinicians, educators and researchers contributing to our understanding of trauma and its treatment.
I don’t remember reading a professional book in several intense sittings like I just did with your new book, The Body Keeps The Score: Brain, Mind, and Body in the Healing of Trauma. It’s been praised by everyone from Jon Kabat-Zinn and Francine Shapiro to Jack Kornfield, Peter Levine and Judith Herman, who called it a “masterpiece that combines the boundless curiosity of the scientist, the erudition of the scholar, and the passion of the truth teller.” (Read an excerpt from the book accompanying this interview.)
Let me start with some basics: Could you say something about why talk therapy alone doesn’t work when treating trauma?
Bessel van der Kolk: From my vantage point as a researcher we know that the impact of trauma is upon the survival or animal part of the brain. That means that our automatic danger signals are disturbed, and we become hyper- or hypo-active: aroused or numbed out. We become like frightened animals. We cannot reason ourselves out of being frightened or upset.
Of course, talking can be very helpful in acknowledging the reality about what’s happened and how it’s affected you, but talking about it doesn’t put it behind you because it doesn’t go deep enough into the survival brain.
DB: Would you say that is one of the distinctions between your work and Edna Foa’s “prolonged exposure therapy”? In a New Yorker article on trauma, Foa talked about rewriting memories, rather than destroying them, and describes her work with a patient with PTSD who had been raped years before: “We asked her to tell the story of that New Year’s Eve (when the rape occurred) and repeat it many times….to distinguish between remembering what happened in the past and actually being back there…and when, finally, the woman did that she realized that the terror and her rape were not her fault.”That sounds like cognitive learning.
Bv: That’s a lovely example of the ability of talk to get a better perspective. But there is a mistaken notion that trauma is primarily about memory—the story of what has happened; and that is probably often true for the first few days after the traumatic event, but then a cascade of defenses precipitate a variety of reactions in mind and brain that are attempts to blunt the impact of the ongoing sense of threat, but which tend to set up their own plethora of problems. So, trying to find a chemical to abolish bad memories is an interesting academic enterprise, but it’s unlikely to help many patients. It’s a too-simplistic view in my opinion. Your whole mind, brain and sense of self is changed in response to trauma.
In the long term the largest problem of being traumatized is that it’s hard to feel that anything that’s going on around you really matters. It is difficult to love and take care of people and get involved in pleasure and engagements because your brain has been re-organized to deal with danger.
It is only partly an issue of consciousness. Much has to do with unconscious parts of the brain that keep interpreting the world as being dangerous and frightening and feeling helpless. You know you shouldn’t feel that way, but you do, and that makes you feel defective and ashamed.

EMDR and Body Awareness Approaches to Trauma Treatment

DB: You are a big proponent of body awareness approaches to trauma treatment—and for a fully lived life. For example, you’ve done research on yoga for trauma survivors and recommend yoga for patients. I saw recently that your Trauma Center offers trainings to yoga teachers in working with the trauma of their students. You also speak very highly of the body-oriented therapies of Peter Levine and Pat Ogden, and especially of EMDR. You devote a whole chapter to your learning EMDR and examples of your use of it.
Bv: We have done the only NIMH-funded study on EMDR. As of 2014, the results of that study were more positive than any published study of those who developed their PTSD in reaction to a traumatic event as an adult.
There are opinions and there are facts.
Traumatized people often become insensible to themselves. They find it difficult to sense pleasure and to feel engaged. These understandings force us to use methods to awaken the sensory modalities in the person.
The facts are that the EMDR study was spectacularly successful in adults, a bit less with childhood trauma–at least not in the short period of time (eight 90-minute sessions) in the research protocol. But our research found that the impact of trauma is in the somatosensory self, trauma changes the insula, the self-awareness systems. Traumatized people often become insensible to themselves. They find it difficult to sense pleasure and to feel engaged. These understandings force us to use methods to awaken the sensory modalities in the person.
DB: The following quote from your book beautifully addresses some of this:
“The neuroscience of selfhood and agency validates the kinds of somatic therapies that my friends Peter Levine and Pat Ogden have developed…. [In] essence their aim is threefold:

  • to draw out the sensory information that is blocked and frozen by trauma;
  • to help patients befriend (rather than suppress) the energies released by that inner experience;
  • to complete the self-preserving physical actions that were thwarted when they were trapped, restrained, or immobilized by terror. 

Our gut feelings signal what is safe, life sustaining, or threatening, even if we cannot quite explain why we feel a particular way. Our sensory interiority continuously sends us subtle messages about the needs of our organism. Gut feelings also help us to evaluate what is going on around us. They warn us that the guy who is approaching feels creepy, but they also convey that a room with western exposure surrounded by daylilies makes us feel serene. If you have a comfortable connection with your inner sensations—if you can trust them to give you accurate information—you will feel in charge of your body, your feelings, and your self” (p.96).

EMDR trainers now seem to be focusing more on sensory modalities than when I first was taught about EMDR, and they also use “resource installation” (Leeds) and more recently “dyadic resourcing” (Manfield). But if there has been an identified single trauma that doesn’t resolve after several sessions, they look for an older “feeder memory,” and get there by asking the patient to focus on body sensations to see if he or she has ever felt those sensations before. It often is a gateway to an earlier trauma.
Bv: A lot of different schools do that, where the body is a pronounced part of therapy. My own teacher, Elvin Semrad, in the early 1970s in Boston, was very somatically oriented; same thing for Milton Erikson and many schools of hypnotherapy. Most people I hang out with who work with traumatic stress are somatically oriented.

The Limits of CBT

DB: The popular media are often puzzlingly ignorant about the nature of trauma and its treatment. You are very well aware of this, but an otherwise interesting article in the May, 2014 issue of The New Yorker magazine stated that a study “published in Nature in 2010, offered the first clear suggestion that it might be possible to provide long-term treatment for people who suffer from PTSD and other anxiety disorders without drugs.” That article never even mentioned EMDR, which was listed in a 1998 task force report of the Clinical Division of the American Psychological Association as being one of three psychological therapies (together with exposure and stress inoculation therapy) empirically supported for the treatment of PTSD. How could they miss that?
Bv: Well, they often get things not quite right! It intrigues me how the public is much more fascinated with the potential of false memories in patients than in the gross distortions of our society’s memory of trauma.
Articles like the one you cited often relate to the study of memories in mice. It is a huge leap, of course, from rodents to human beings, which not only leads to misinformation about the nature of traumatic stress and its treatments, but also about the rather trenchant differences between humans and mice. Humans are profoundly social animals—everything we do and think is in relation to a larger tribe. Our brains are cultural organs. It probably has something to do with people’s temperaments; people who do rodent research are drawn to the simplicity of rodent brains. In order to work with humans you need to have a taste for culture, complexity and uncertainty. People would be astonished if a psychotherapist gave advice to rodent researchers on how to run their labs! But the popular press takes the liberty of making these misinformed leaps with the general public all the time.
DB: How best to treat trauma is a crucial question, of course. You saw CBS’ 60 Minutes television show that first aired in November, 2013, describing a Veterans Administration program treating war veterans using “cognitive processing therapy” and prolonged exposure treatment methods. Your understanding of and approach to treating trauma is very different. Can you address a couple of points that distinguish your views from those presented by that VA treatment program?
Bv: Cognitive Behavioral Therapy (and “Trauma Focused CBT”), talk therapies, and prolonged exposure therapies can make some changes in people’s distress, but traumatic stress has little to do with cognition—it emanates from the emotional part of the brain that is rewired to constantly send out messages of dangers and distress, with the result that it becomes difficult to feel fully alive in the present. Blasting people with the memories of the trauma may lead to desensitization and numbing, but it does not lead to integration: an organic awareness that the event is over, and that you are fully alive in the present. The VA seems to be surprised by how many veterans drop out of prolonged exposure therapy. It would be helpful for them to find out why, but the likely answer is that it is re-traumatizing them.
DB: More recently, there was the profile of your work with trauma in the Sunday Magazine of the New York Times (May 22, 2014). The author shadowed you for a month, and it seemed to me that the article minimized the outcome of the clinical demonstration you did with an Iraqi war veteran at an Esalen Institute workshop.
Bv: The current Family Therapy Networker magazine just ran a piece about all the inaccuracies in that article, and the difficulties journalists have in getting the story straight. “Eugene” was the participant in the workshop, and he said “The takeaway when I read [the New York Times article] was that I was confused by the experience and that it didn’t help, which just isn’t true…When I spoke with the reporter, I said very positive things about the concrete ways that it helped me in terms of physical symptoms that disappeared, and also the fact that Dr. van der Kolk recommended people for me to work with afterward. He really spent some time finding a good recommendation for EMDR, and it really helps.” He wrote a letter to that effect and they wouldn’t publish it. I just got an email from him with a picture of my new book saying, “Thank you for helping me to regain the capacity for calmness and focus to be able to engage, and read books again.”
DB: The New York Times article also quoted sound bites from some other researchers, seemingly questioning your work, but later corrected some misinformation.
Bv: That’s another intriguing issue. There seems to be a tendency among therapists to become very religious about their own particular method—some seem to be more committed to their method than to the welfare of their patients. When patients don’t improve, they blame their resistance, and slam the people who point out that one size never fits all. The New York Times article also alluded to the Roman Catholic Church’s problems with clergy abuse and trying to defend itself by claiming that these plaintiffs suffered from “false memories,” and were the victims of “repressed memory therapy.” Testifying on behalf of pedophiles became a whole industry that seems to have entirely disappeared now that these trials are over.
DB: The newspaper did publish your brief (and, I thought, restrained!) rejoinder clarifying the issues presented, and you received an overwhelmingly supportive response in other letters to the editor and online comments. Here’s an excerpt from your letter to the New York Times:
Trauma is much more than a story about the past that explains why people are frightened, angry or out of control. Trauma is re-experienced in the present, not as a story, but as profoundly disturbing physical sensations and emotions that may not be consciously associated with memories of past trauma. Terror, rage and helplessness are manifested as bodily reactions, like a pounding heart, nausea, gut-wrenching sensations and characteristic body movements that signify collapse, rigidity or rage…. The challenge in recovering from trauma is to learn to tolerate feeling what you feel and knowing what you know without becoming overwhelmed. There are many ways to achieve this, but all involve establishing a sense of safety and the regulation of physiological arousal.
Bv: I also mentioned in the Networker article, “What happened …is a reflection of the incredible difficulties society has with staring trauma in the face and providing people with the facts of what happens, how bad it is, and how well treatments work.”

Talent and Compassion Aren’t Enough

DB: I appreciate your emphasis on research and fact-based discussions versus theoretical ones. Along those lines, George Silberschatz, a past-president of the international Society for Psychotherapy Research, said in a recent interview that the between-therapist effects were as large if not larger than the between-treatment effects in current psychotherapy research, and this is perhaps from non-specific treatment effects.
Bv: Well, talent and compassion are central elements of being an effective therapist, but learning to feel your feelings and be in charge of your self, and working with someone who knows how to deal with bodily sensations and impulses can make all the difference between visiting an understanding friend once a week, and actually healing your trauma.
DB: Could it relate to Stephen Porges’ description of the Polyvagal Theory and the social engagement system? The nonspecific treatment effects from psychotherapy research seem to be powerful about the therapist helping to create a safe environment.
Bv: I have been very much inspired by Porges’ work. The reason that Porges has become an important part of our world is his finding that trauma interferes with face-to-face communication. It is very important how you get regulated in the presence of other people. We need to learn very specific ways to activate the social engagement system. Sitting in your chair and chatting might not always be the most effective way of doing that.

Porges’ work was very helpful and clarifying about where in the brain trauma makes it difficult to feel comfort, to feel intimate and connected with other people. Knowing those things can help therapists to become more conscious about the specifics of their interactions, and should become part of the training of therapists. For example, I recently took a month-long intensive training course for Shakespearean actors to learn how the modulations of my voice, the configurations of my facial muscles, and the attitudes of my body affect my self-experience, and that of the people around me.
Porges’ work points to the importance of working with the reptilian brain—the brain stem, as well as the limbic system. We need to teach breathing and movement and work with the parts of the brain that are most impacted by trauma—areas that the conscious brain has no access to.
So I am dubious about the nonspecific relational impact of treatment on benefiting traumatized individuals. Seeing someone nonspecifically does not help the fear circuits and that collapsed sense of self. We need to learn very specific ways to activate the social engagement system. Sitting in your chair and chatting might not always be the most effective way of doing that.
DB: A colleague of yours from your Harvard days, neuroscientist Catherine Kerr, recently writing about mindfulness research, said:
The placebo effect is usually defined, somewhat tortuously, as the sum of the nonspecific effects that are not hypothesized to be the direct mechanism of treatment. For example, having a face-to-face conversation is not hypothesized as what makes psychotherapy work—you could have a face-to-face conversation with anybody. But for some reason, if you go every week to therapy, you are going to get better. But you could talk about the weather! When we perform these rituals with a desire to get better, we often do. We now know that a lot of the positive therapeutic benefit from psychotherapy and from various pain drugs may come from that initial context; it often has nothing to do with the specific treatment that is being offered. It is really just about the person approaching a situation with a sense of hope and being met by something that seems to hold out that hope (October 01, 2014, Tricycle Magazine).
And I think Allan Schore at UCLA would say that there is “unconscious right brain to unconscious right brain communication” going on, between therapists and patients, or between any of us in close relationships that might be what is otherwise thought to be “nonspecific” in therapy research. A deep ability to be present and connect empathically with patients is easier for some individual therapists than for others. Perhaps we are discussing a situation in therapy of “necessary, but not sufficient!”
Bv: I can’t really comment on all that—you’ll have to ask Catherine Kerr and Allan Schore. I have always been a bit puzzled about that “right brain to right brain” stuff. The research shows that the part of the brain most impacted by trauma is the left hemisphere, and I would imagine that every single part of the brain is necessary for effective functioning and feeling fully alive in the present.
DB: Well, I will be interviewing Schore next month, so we now have some good material to discuss!
Bv: I’ll look forward to reading that.

Neurofeedback & Yoga

DB: Is there anything in your own thinking that you feel has significantly changed in the last couple of years due to your continuing growth in the work and in all you are exposed to?
Bv: The biggest has been my exposure to neurofeedback (a type of biofeedback that focuses on brain waves, instead of peripheral phenomena like heart rate and skin conductance). In neurofeedback you change your brain’s electrical activity by playing computer games with your own brain waves. Learning how to interpret quantitative EEG’s helped me to visualize better how the brain processes information, and how disorganized the brain becomes in response to trauma. What made it necessary to look for other, non-interpersonally-based therapies was the realization, followed by research that dramatically illustrated how being traumatized may interfere with the ability to engage with other human beings to feel curious, open and alive.
Learning how to interpret quantitative EEGs allowed me to actually visualize what parts of the brain are distorted by traumatic experiences, and this can help us target specific brain areas where there is abnormal activity and where the problem actually is.
The trauma is not the story of what happened long ago; the long-term trauma is that you are robbed of feeling fully alive and in charge of your self.
For example, for the part of the brain supposed to be in charge, after trauma it will have excessive activity, keeping people in a state of chronic arousal—making it difficult to sleep, hard to engage and to relax. We find neurofeedback can change the activity in parts of the brain to allow it to be more calm and self-observant.
In another example, the frontal lobes of traumatized people often have activity similar to that of kids with ADHD, which makes it difficult to attend with the subtlety that we need to lead nuanced lives.
DB: So would the neurofeedback be with or without exposure to a particular traumatic memory?
Bv: Again, traumatic stress results in not being able to fully engage in the present. The trauma is not the story of what happened long ago; the long-term trauma is that you are robbed of feeling fully alive and in charge of your self.
DB: You would say that also is a positive outcome from yoga and other body awareness exercises, activating and strengthening the parasympathetic nervous system?
Bv: In our NIH-funded yoga for PTSD study we saw people did considerably better after 8 weeks of yoga. It can make a contribution to help people be more present in the here and now. The whole brain gets reorganized. Some quotes from participants in that study included:

  • “My emotions feel more powerful. Maybe it’s just that I can recognize them now.”
  • “I can express my feelings more because I can recognize them more. I feel them in my body, recognize them, and address them.”

This research needs much more work, but it opens up new perspectives on how actions that involve noticing and befriending the sensations in our bodies can produce profound changes in both mind and brain that can lead to healing from trauma. When we understand these things about the brain, how it works, we learn more about how to adjust our treatments.

DB: I’ve heard you say that you do not identify as belonging to any one particular school of therapy; that you do not even identify as an EMDR therapist even though you often utilize it.
Bv: Well, that would be like a carpenter saying he was a “hammer carpenter.” We need many different tools that will work for different patients and different problems.

Meaningless Pseudo-Diagnoses

DB: Can you talk a bit about your battles to get deeper and more sophisticated understandings of trauma treatment into the professional arena? Your book recounts the research you did that identified a traumatized population quite distinct from the combat soldiers and accident victims for whom the PTSD diagnosis had been created.
Bv: Yes, well, in the early 1990’s our PTSD work group for the Diagnostic and Statistical Manual of Mental Disorders voted nineteen to two to create a new diagnosis for victims of interpersonal trauma: “Disorders of Extreme Stress, Not Otherwise Specified” (DESNOS), or “Complex PTSD” for short. But when the DSM-IV was published in May 1994 the diagnosis did not appear in the final product.
Fifteen years later, in 2009, we lobbied to have “Developmental Trauma Disorder” listed in the DSM-5. We marshaled a lot of support, such as that from the National Association of State Mental Health Program Directors, who serve 6.1 million people annually, with a combined budget of $29.5 billion.

Everybody who holds forth should have a practice, otherwise you get seduced by your ideas and don’t get confronted with the limits of your ideas in clinical practice.
Their letter of support concluded: “We urge the American Psychiatric Association to add developmental trauma to its list of priority areas to clarify and better characterize its course and clinical sequelae and to emphasize the strong need to address developmental trauma in the assessment of patients.”
It was turned down also, and a lot of criticism of DSM-5’s approach has since been levied and they have lost credibility from a variety of professional sources.
DB: You recently published the results of an international survey of clinicians on the clinical significance of a Developmental Trauma Disorder diagnosis. Can you tell us why it might be so beneficial to have such a diagnosis?
Bv: Because it would help us to start focusing on helping kids feel safe and in control , rather than labeling them with meaningless pseudo-diagnoses like oppositional defiant disorder, impulse control disorder, self-injury disorder, etc.
DB: A significant part of your career at the Trauma Center has been working with traumatized children. There is a lot in your book relevant to work with children.
Bv: Yes, with Joseph Spinazzola and Julian Ford, we are involved in studies through the Complex Trauma Treatment Network of the National Child Traumatic Stress Network, which now is comprised of 164 institutions in almost all States.
DB: You are doing so much traveling with international teaching, you are involved in ongoing research, and you have quite a large staff at the Trauma Center in Boston to manage.
Bv: About 40 people are working at the trauma center now.
DB: Are you still personally able to do one-on-one clinical work or only have a supervisory role?
Bv: Everybody who holds forth should have a practice, otherwise you get seduced by your ideas and don’t get confronted with the limits of your ideas in clinical practice.

Posttraumatic Growth and Aliveness

DB: I’ve always liked the subtitle of Peter Levine’s book Waking the Tiger: Through Trauma Into Aliveness. Others are talking about “posttraumatic growth.”
Bv: That’s what the New York Times article should have been about. The guy they described so poorly actually recouped his life. People get better by befriending themselves. People can leave the trauma behind if they learn to feel safe in their bodies—they can feel the pleasure to know what they know and feel what they feel. The brain does change because of trauma and now we have tools to help people be quiet and present versus hijacked by the past. The question is: Will these tools become available to most people?
DB: You are certainly doing your part, Bessel, by being so very active and productive. I counted 35 workshops out-of-town on your calendar for 2014, in addition to your teaching at the various medical schools in Boston, at the Trauma Center and a new certification program. Right now you are about to embark on a 10-day bo