Trauma: To relive or not to relive
Stuart D. Perlman, Ph.D.
The extent, if any, to which trauma needs to be relived is one of the most important and controversial issues in the field of psychotherapy today. Some critics of psychotherapy charge that the reliving of trauma has become an iatrogenic moneymaking creation of therapists. Even more sympathetic voices question the necessity and usefulness of reliving trauma. Some suggest other techniques that can be effective without arousing the pain and disorganization of reliving. However this is a very complicated issue, where black and white issues of reliving vs. not reliving are not a sophisticated enough understanding for optimal treatment of survivors.
At the Self Psychology Conferences held over the past several years central panels (Groves (1998), Weisel-Barth (2000), Pickles (2001), and Carlton (2004)) have been repetitively addressing parts of the controversy in the treatment of severe trauma survivors: Critiqued for missing opportunities for deeper treatment by protecting a patient from the experience of intense affects in the reliving trauma, Weisel-Barth responded that the patient was too frightened to be allowed to go into the negative transference too deeply or for too long, that the patient might have bolted treatment and that the patient needed the new experience of a soothing relationship. In contrast, Friedman, a discussant of Carlton’s paper, argued that the treatment described by Carlton encouraged too much reliving of trauma and not enough medication, suppression of affects, and alternate interventions, and, as a result, the patient’s entire life structure was unnecessarily disrupted by the process. Others have similarly critiqued the reliving allowed by Carlton as “deepening the grooves of the traumatic pathways” and, therefore, reinforcing the traumatic experience and response style. Carlton defended her approach saying that treatments can miss the core of a patient’s experience if they fail adequately to explore traumatic material through reliving it.
Comments from my own patients confirm how delicately nuanced are the answers to the questions about reliving trauma. An emotionally neglected physically tortured patient told me after reading this paper that, for her, the pain of reliving trauma is insignificant in comparison to her daily experience of living. On the other hand, another patient, who was herself and observed her sister being massively abused by her father was approached by this sister, when this sister began to have childhood memories of abuse as an adult. My patient asked her sister a series of questions: was she was suicidal, getting along with her husband, children and at work? The sister answered she was functioning well. So my patient said, “If you can continue in that way then don’t start stirring the shit at least until your kids get out of high school. If anything changes then call me back and we can discuss it again.” Perhaps most poignantly, a patient suffering from severe dissociative identity disorder as a result of horrible trauma, said to me, “I know that reclaiming and reliving these horrible experiences is so painful for me but I want them and need them because they make me feel more solidly myself.”
Decisions about treatment, including re-living trauma, needed to be guided by the fact that treatment occurs in the context of a relationship in which the patient needs to be an active participant, empowered to collaborate with the therapist to make decisions. As Kohut said, the patient may know what is best for his or her self even more than the analyst, and we need to follow his or her wishes as much as possible (Kohut, 1977, pp.19-20). To interpret a patient’s wishes about the re-living process, a therapist needs to consider what self-states are being expressed, whether communications are about a current experience, the time in the treatment process when the wishes are communicated, and cultural and other issues. To the extent that trauma is relived, it is relived in pieces integrated over time, and, as treatment progresses, on an on-going basis, a therapist can test perceptions with the patient and reach and revisit understandings and agreements about the reliving process. Only by employing such a dialogue can a therapist hope to structure a treatment that permits a patient appropriately to re-experience trauma within tolerable levels.
Some of the specific issues that arise in the process of treating trauma survivors are discussed in my book, The therapist’s emotional survival: Dealing with the pain of exploring trauma (1999). However, I would like to highlight a number of the issues here.
Trust and fear of retraumatization are issues of central concern for trauma survivors who, by the nature of their trauma, had rights ripped away from them and their integrity invaded. Ironically the therapeutic process uses the human relationship as the primary agent of change for patients, who have usually been brutalized by others, especially authority figures. Patients have to feel sufficiently safe and connected to work through their inevitable fears with the therapist. Being sensitized to this has led me to a basic concept of treatment, “process over content,” or first be a “genuinely good human-being to the patient and then a psychoanalyst.” Always treat the patient with respect and caring; these are much more important than any details or content in the therapeutic dialogue. My experience treating trauma survivors has shown me that I do not need to push to find the pain and to “recover” memories. I have found that if I make the therapy as safe as possible and remain as present and connected as possible, the patient will find and do what they need to do for that moment in treatment.
The dance of the tolerances of affect between and within the patient and therapist is central to the treatment of trauma survivors in general. The therapist’s capacity to contain the pain and hear it, is consciously and unconsciously monitored by the patient and vs. versa. It is difficult for therapists to hold onto hope while resonating with the deep pain of a trauma patient. Due to space limitations I will not focus on this and other therapist countertransference or the tendency to impact the patient’s healing as a result of the triggering of the therapist’s own issues and trauma.
Many new approaches to trauma treatment actually start with teaching the patient affect management and ways of reducing over-stimulation and the pain of reliving. These techniques are, at times, useful adjuncts but they are not the heart and soul of treatment. These approaches use meditation, yoga, relaxation exercises, psychotropic medications, acupuncture, Oriental medicine and herbs, and other interventions.
Reliving of trauma is usually helpful when the therapist can help the patient track his or her affects during the reliving process, but there needs to be awareness that repeatedly reliving trauma without some felt positive connection to the therapist, can reinforce a patient’s perception of the traumatic nature of the world. Encouraging such reliving is the emotional equivalent of having the patient stick his or her finger in a light plug socket repetitively. On the other hand, associating the caring therapist with the old painful memories can reshape perceptions and fades the power of trauma’s pain. However, while we therapists intend our presence to be soothing to patients, we cannot assume that a patient experiences it that way. We need to keep checking to see how the patient is actually experiencing us, and noting in particular if and/or when our communications results in unwanted intrusion, a pressure on the patient to leave their experience and respond to us.
I believe the ends of psychotherapy sessions and the time in between sessions are crucial in the treatment of trauma survivors, because they so easily become assimilated into experiences of devastating abandonment. We cannot always protect our patients from such experiences but we can track these feelings and try to make sense of them together. If we are successful in this effort, the patient can often regroup and cope with the world in a less disrupted fashion.
The difference between reliving trauma and dealing with different self-states needs to be understood by therapists in order to properly interpret the patient’s communications. As a result of their trauma, patients may have massive splits in their experience. In the Carlton presentation I believe some of what was called reliving was actually frozen self-states that were calling out for help and needed to be heard by the therapist. This is different than actual reliving in that these different self-states need to be addressed separately, not as though they were past experiences but as the current experiences that they are. They need help dealing with trauma in order to be set free to eventually relate to and integrate with other parts of the person.
Another complex issue of which therapists need to be aware is how to track the stages of recovery. Having treated many trauma survivors, some for as long as 22 years, I believe that there are stages. In the first stage, which I call “establishing safety and connection,” the patient needs to know that the therapist is not going to harm them and can be trusted to be present to listen to them and help them regulate his or her affect. The second stage involves the therapist being willing to follow the patient into the depth of the horrors and the consequences of the trauma in forming and sculpting their life path and, many times, their destructive patterns. Patients going through the reliving stage will often lose some functioning, when personality structures of a lifetime need to be shed in order to form the basis for a new way of being in the world. This loss of functioning scares many therapists and they may lose faith in the process. But then there is a further stage of recovery when the patient has found the outline of what happened to them, opened up to the painful, traumatic moments enough and recaptured major pieces of his being. No longer needing to relive the trauma and able to initiate compensatory behavior in response to recognized triggers, the patient can begin to focus on developing a post-traumatic life, encircled by people who are nurturing.
I would like to end this op-ed piece with praise of anyone who is willing to sit in the consulting room with a trauma survivor and try to be present and helpful. This is excruciatingly difficult work for the therapist and we all need each other’s support because it takes a village, a community, and a supportive psychoanalytic movement to create a context within which treatment like this can be done.
Carlton, L. (2004). Struggling out of the box. Presented at the Annual conference on the Psychology of the Self, San Diego, California, November.
Groves, A. (1998). The multiple faces of trauma. Presented at the Annual conference on the Psychology of the Self, San Diego, California, October.
Kohut, H. (1977). The restoration of the self. New York: International Universities Press.
Perlman, S. (1993). Unlocking incest memories: Preoedipal transference, countertransference, and the body. Journal of the American Academy of Psychoanalysis, 21 (3), pp. 363-386.
Perlman, S. (1995). One analyst’s journey into darkness: Countertransference resistance to recognizing sexual abuse, ritual abuse, and multiple personality disorders. Journal of the American Academy of Psychoanalysis, 23(1), pp. 137-151.
Perlman, S. (1999). The therapist’s emotional survival: Dealing with the pain of exploring trauma. Lanham, Maryland: Rowan and Littlefield.
Pickles, J. (2001) Alone Together: My work with a severely traumatized woman. Presented at the Annual conference on the Psychology of the Self, San Francisco, California, November.
Weisel-Barth, J. (2000). The role of the relationship in the therapeutic process. Presented at the Annual conference on the Psychology of the Self, Chicago, Illinois, November.