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When severe emotional damage prevents brief therapy…

Julie Lawrence explains some complex forms of PTSD caused by severe emotional harm in childhood, and explores a role for HG therapists. And Emily Gajewski shares her case experience below.


“It seemed like it was happening to someone else”

NAN came to me for therapy because she thought she was having a “nervous breakdown”. Matters had come to a head when she lost her phone, which left her crying uncontrollably for a whole day. Even recalling the loss of the phone during the session made her extremely emotional. She kept repeating, “I lost my phone!” and her crying had an infantile quality. Between crying episodes, she seemed wary, unable to describe either how she felt or why the phone loss had affected her so deeply. She had no memory of anything from the past that might have triggered such a reaction – indeed, she had only a hazy recollection of her childhood at all. She clearly had symptoms of depression, so we agreed to focus on that In the next session

In the next session, she started to talk about her problematic relationship with her parents. She was preoccupied with speaking to them, and visiting them, both of which made her miserable, yet she felt compelled to do it. This led to a memory from childhood which involved a prolonged beating from her mother – she could not fully bring this memory into mind, but reconnecting with it created the same type of uncontrollable crying she had experienced in the first session. She also talked about her partner being violent and described a “strange state” she went into when he hit her, a state “like not being there”, which she said she had experienced a lot. It was at this point that I realised that she had been experiencing dissociation – disconnection from the world around her.

When I questioned her, she reported other phenomena of that kind, such as feeling that her image in photographs “was not me”. It struck me that there had been clues to her dissociation in the first session, which I had missed. For instance, she often appeared spaced out, couldn’t describe or locate feelings in her body, and seemed detached from bodily sensations.

Many people who have undergone severe trauma, particularly early trauma involving abuse, describe dissociating during the experience: some may report floating outside the body and watching the scene from afar, going into a dream like state or seeing magical colours, patterns or shapes, which prevented the pain of the event from reaching consciousness. As a result, they may have fragmented or absent memories for the details of what happened. One young woman who experienced sexual abuse as a child, which led on to sex trafficking, had the courage to tell her story at the Human Givens Institute conference in Dublin this year. She described how the only way she could survive the sexual abuse “was to leave my body – literally, I had to go up to the corner of the ceiling and watch it from there”. She expressed her gratitude to the human givens counsellor who, in two sessions, using the rewind detraumatisation technique, enabled her to reclaim her life, go back to college and start pursuing a professional career.

However, many people, like Nan, not only experience dissociative phenomena as a result of severe trauma but may have highly complex and enduring difficulties that affect their personalities and their coping mechanisms for getting through life. Yet that might not initially be apparent to a therapist from whom they seek help. For instance, Carla sought therapy for binge eating: she would drive out late every night to the supermarket and buy large quantities of food to eat. Later, it emerged that she became obsessive and clingy with boyfriends, ultimately alienating them; then she would stalk them online until she met a new partner and the cycle would begin again. She reported a normal childhood and no traumatic memories but, over a number of sessions, it emerged that her mother had been a neglectful parent and Carla had spent long periods alone. She realised that this had often caused her to ‘space out’, which was how she dealt with problems. 

This article looks at dissociative and related phenomena through the lens of the human givens, and the degree to which we can use our rich store of techniques to help clients heal. Although the work is much less likely to be short term, as human givens therapists normally expect, there can be good results. Nan, for instance, was able to leave her abusive partner after a number of sessions and stop obsessively contacting her parents, which seemed a positive step for her wellbeing, while the rewind detraumatisation technique helped Carla, along with learning better coping skills. Therapists should be aware, however, that there are special challenges involved in working with this client group, who are usually both extremely vulnerable and demanding. It is important to take a realistic view of the limits of our individual expertise and the commitment we are prepared to make to such clients, and to seek supervision at the outset, if in doubt about skill and experience level.

Why dissociation?

We all dissociate at times. It just means not being in the current moment – we do it, for instance, whenever we daydream. But different mechanisms are involved when we dissociate in times of extreme trauma. Recent research suggests that this ability is part of an ancient defence system which predates the flight-or-flight mechanism, as there are analogues of it even in primitive creatures such as reptiles.1 Variously termed collapse–feign-death, collapse–submit, freeze2 or fawn, it is an extreme protective response enlisted only when a predator makes physical contact with its prey: the prey’s blood pressure drops, minimising bleeding; breathing slows; muscle paralysis occurs, stopping the animal from struggling and increasing injury – potentially convincing the predator that it is dead and, therefore, not about to escape; its body and brain are flooded with endorphins, reducing pain and psychological distress; and it may empty its bladder and bowels, creating the impression that it is contaminated and dangerous to eat. When this system is activated in humans, amnesia or fragmented memory of the traumatising event commonly occurs. It is not clear how this supports survival but it may be that switching off core consciousness and memory is necessary for achieving reduced respiration, paralysis and pain relief.

As human givens practitioners, we are familiar with the two main divisions of the autonomic nervous system: the sympathetic (associated with emotional arousal and the flight-or-flight response) and the parasympathetic (rest and digest). We work to calm our clients so that they can respond to us and our interventions – in effect, activating the social engagement system,1 the most recently evolved part of the parasympathetic nervous system, which picks up calming signals from others’ body language, tone and expressions. The collapse–feign-death response is activated by another, more ancient part of the parasympathetic nervous system (it first appears in the fetus’s brain stem just nine weeks postfertilisation3), which deals with survival in extreme events. This creates the extreme parasympathetic state of low blood pressure, low respiration, paralysis, etc, which we see in this response (see below).

 
  • High blood pressure
  • Fast breathing and heart rate
  • Hyper awareness of surroundings
  • Ready for fast aerobic activity
  • High arousal
  • Fight or flight
  • Normal blood pressure
  • Regular breathing and heart rate
  • Normal awareness of surroundings
  • Active to tend and befriend or rest and digest
  • Medium arousal
  • Social engagement
  • Low blood pressure
  • Slow breathing and heart rate
  • Loss of awareness of surroundings
  • Analgesia
  • Amnesia
  • Low arousal
  • Collapse–feign-death

Minton, K, Ogden, P and Pain, S (2006).
Trauma and the Body. Norton

Both flight-or-flight and collapse–feign-death responses promote short-term survival but carry longer-term risks. Both can result in the dissociated memory state, which leaves material that is not fully processed lodged in the brain’s amygdala, creating the symptoms of PTSD, such as panic attacks and intrusive memories. However, these systems are not mutually exclusive and often the flight-or-flight system is activated first, with the collapse–feign-death activated afterwards. Thus, after the traumatic event, a person may suffer high levels of arousal, hypervigilance, overreaction, etc, but also a more severe dissociative reaction, caused by disturbances in memory and consciousness unique to the collapse– feign-death defence. This is particularly likely if the trauma features long-term abuse from a young age, particularly sexual abuse by a family member or trusted carer. (I would suggest that the problems caused are analogous to those of molar memories, whereby a pleasurable or positive urge (including anger) is suddenly overtaken by a negative emotion such as shame, leaving the nervous system primed for the uncompleted initial impulse.4)

PTSD after collapse–feign-death responses

So what types of additional problems are we looking at? They are behaviours usually arising from trauma that was severe and ongoing but which often get dumped under a label, in psychiatric classification systems, such as ‘complex PTSD’ – a cluster of symptoms which, in addition to high arousal, hypervigilance, avoidance and intrusive memories of classic PTSD, includes inability to trust others, patterns of disturbed relationships, losing attention or concentration (dissociation), somatic symptoms and unreliable recall of events – or ‘borderline personality disorder’ – the main symptoms of which are given as extremely poor regulation of emotions, swings between idealisation and devaluation of others, poor impulse control, feeling out of touch with reality, and distortion of self-image, resulting in poor selfesteem. Clients with such problems seem particularly prone to substance abuse and self-harm and, in their desperation to get their emotional needs met (particularly their need for security, which has been severely compromised in the past), they may appear demanding, manipulative and difficult. (It is important to be mindful that all these kinds of symptoms can also be seen in people on the autistic spectrum, where trauma may occur not only as a result of severe abuse but also from feeling lost in a seemingly alien world.5)

At the very extreme end of this spectrum of symptoms lies what has been termed ‘dissociative identity disorder’ – where the lack of integrated memories and consciousness is so severe that a person appears to have several different ‘personalities’, and shows apparently normal behaviour interspersed with extreme states of high emotional arousal. The existence of such a condition is a matter of controversy but may perhaps be a rare, unconscious response to extremeabuse. (It is a known fact, however, that therapists can, wittingly or unwittingly, induce different personalities.)

Clues to more complex forms of PTSD

Poor autobiographical memory Unlike the PTSD sufferer, who usually has a vivid and detailed memory of every aspect of the trauma, the opposite can be true after a trauma which has provoked the collapse–feign-death state. In extreme cases involving childhood abuse, especially by relations, not only will memory for the traumas be hazy but also for childhood more generally, as the memory disruption spreads over to other events happening at the time as well.

Poor memory needs to be treated with caution. During information gathering, therapists need stringently to avoid making suggestions to the client which might implant false memories. It is, therefore, crucial to consider the whole picture and the presence of other symptoms.

Disturbance of consciousness People may display sudden changes in their usual personal style, body language, tone, etc. A client may also report ‘losing’ periods of time, being told of activities they cannot remember, or coming across possessions they don’t recall moving or buying.

Shame Clients may be ashamed that, by shutting down, they ‘let’ the abuse happen. Or they may express an inordinate amount of shame over consequent out-of-control behaviours, readily pattern matching to these. Conversely, shame might promote further suppression of memory and outward denial.

Habitual dissociation For those who have suffered long-term abuse, a dissociative coping style may become the default response to challenge, preventing them from getting emotional needs met. It may also expose them to re-victimisation, if they bypass the instinct to resist predatory individuals. When challenged or when challenges are suggested in therapy, a client may appear to ‘space out’.

Self-harm When clients habitually dissociate, they are also more at risk of non-suicidal selfharm. I would suggest that a significant proportion of self-harm could be a means of deliberately activating the collapse–feign-death response to reduce unpleasant feelings of over-arousal. Selfharming would give the same endorphin rush, ‘spaced-out’ feelings and sense of relief as when the collapse–feign-death response kicks in during a trauma.

Distorted views of the abuser (click to view: 'The legacy of early ongoing trauma' panel) This can manifest as idealisation of the abuser, a refusal to acknowledge any fault in their behaviour, or a general preoccupation with them, creating an urge to stay in touch and a disproportionate desire for their approval.

Somatic symptoms These are very common among this client group. Entering the collapse–feign-death state during trauma may leave unresolved impulses in the nervous system and create long-term problems in the peripheral nervous system, the immune system, the joints, the gut and the extremities,6 leading to familiar syndromes such as fibromyalgia, ME, IBS, migraines, unexplained pain and arthritis etc.

Disturbance of identity More severely traumatised clients may have an unstable self-image or sense of self, or a more profound sense of not recognising themselves, for instance, in a photograph or in the mirror.

Inability to name feelings When the collapse–feign-death state occurs, the ensuing flood of endorphins blocks communication between the limbic system and neocortex, reducing consciousness. While many clients may have difficulty describing feelings when in an aroused state, the problem is more global and widespread for those with dissociative disorders. (This is very common in high-functioning autism, as well.)

Stalking Infants are born with a strong instinct to be close to their primary carer, even when they have suffered abuse from them. When a parent is consistently abusive or aggressively neglectful, fear inhibits this desire to get close to the parent. This unacted-on impulse may re-surface in later intimate relationships, or any circumstance where a pattern match is made, creating in some cases an overwhelming urge to monitor that person’s whereabouts and seek proximity to them. (This compulsive behaviour would, in human givens parlance, be a molar memory.) Some clients may have a particularly strong response when they experience rejection, echoing the pattern of rejection in infancy.

The experience of dissociation While clients may not remember events clearly after entering the collapse–feign-death state, they do often remember the experience of dissociation itself. Clients may report distorted perceptions – “I was out of my body”; “it was like a dream”; “it seemed far away and very small”; “it was happening to someone else”; “I knew it was happening but it didn’t matter” – shading into direct recollection of the physical experience – “I was paralysed”; “I couldn’t move”; “I couldn’t feel anything”; “suddenly I felt very calm and like I was somewhere else”. Therapy provides a valuable opportunity to educate and normalise such experiences. I have a relative who was raped as a young woman and experienced years of guilt and self-recrimination that she had not fought off her attacker; human givens therapists could explain the ancient defence mechanism which is involved and reframe this as an automatic, life-saving reaction – a brave and sensible way of dealing with an impossible situation.

Using the human givens approach with dissociative clients

Working with such clients is particularly challenging for a number of reasons. First, they often have difficulty trusting other people, and thus may not find it easy to develop rapport with the therapist. Second, poor memory of events combined with distorted views of an abuser may make it difficult for them to communicate past trauma. Third, they often have strong molar memories, creating anger and sometimes stalking behaviours whenever they form close connections – if a therapist works longer term with such a client, they can expect to be on the receiving end of this at some point. Fourth, such clients may resort to serious self-harm; this can be distressing for the therapist, as well as to the clients. Finally, it is essential to be mindful about what the therapist relationship might mean to the client – there might be pattern matches to particular individuals from the past or clients might feel compelled to behave in a certain way because of past patterns. It is important, therefore, that the therapist explores with their client what, or whom, the therapist may represent for them, how that might feel and how to ensure safe boundaries for both parties; if a lot of strong and unpredictable emotion may be expressed, for example, that might include not seeing the client in one’s own home.

Human givens practitioners working with this client group will still find the RIGAAR model framework helpful – rapport building, information gathering, goal setting and agreeing strategies, accessing resources and rehearsal – albeit that there will be additional challenges. For instance, when a client is having difficulty relating or is showing dissociative symptoms, such as spacing out, this can be hard to distinguish from other trance states, such as depression, so it is necessary to use the information-gathering period to gain more insight into the client’s early relationship with caregivers, whether there has been trauma involving the collapse–feign-death state and whether dissociative responses have become habitual. It is worth asking explicitly about the states described in the clues section above, and it may be valuable to use a dissociative disorders screening questionnaire.7 If the therapist does discover evidence of dissociation, it is helpful to normalise these apparently strange states for the client, and educate them about what is happening psychologically and physically. This may help explain to them why they have difficulties such as regulating their emotions or problem solving effectively and lead to goals of learning better coping strategies.

Integrating the traumatic events into normal autobiographical memory using the rewind technique is, as we know, a highly effective means of resolving trauma symptoms. However, it may take several sessions for these clients to be trusting enough to try the technique and some may feel unable to do so at all, however much they might love to let go of old, painful memories. If sufficient trust is built to enable the client to choose to try the rewind, it is worth attempting even if a client has only a vague memory of the traumatic event, as there may well be much better recall in trance. As memories of traumas are often interlinked, rewinding some representative examples of the traumas may well clear the entire trauma pattern, as is the case when rewinding phobias.

The legacy of early ongoing trauma

HAVING emotional needs met in order to thrive is vital in early infancy. The tragic results of needs not met on a major scale were seen years ago in Romanian orphanages where children suffered severe physical and mental retardation and either died or failed to develop crucial innate resources.1

A consistently neglectful parent or carer is likely to do more harm than an intermittently abusive one. As children are fairly resilient, those who experience some trauma but also get love from a parent may still develop sufficient kills and self-confidence to navigate relationships. When neglect or abuse is persistent, however, a child’s brain develops ineffective strategies for relating to others, resulting in lack of trust, histrionic emotions, manipulation,  withdrawal or a variety of other dysfunctional coping methods. The child is at much higher risk of developing dissociative problems.

In extreme circumstances, abuse can lead to a traumatic form of bonding – a tendency best known by the name “Stockholm Syndrome”, after a bank robbery in Stockholm in 1973, during which a number of people taken hostage became emotionally attached to their captors. This instinct, taken together with an understanding of how habitual dissociation can lead people to ignore dangerous cues in their environment, may explain how domestic
violence victims become trapped in a cycle of dependency and violence.

A failure to recognise initial warning signs allows the victim to become involved with an abuser. Then, for those who have been abused in childhood, there may be familiarity in the behaviour pattern of the abuser, involving
intense attention, anger, and controlling and punishing behaviour, interspersed with moments of compassionate care; dissociation during violent episodes may blur the victim’s memory for what occurred.

  1. Gerhardt, S (2014 ). Why Love Matters: how affection shapes a baby’s brain. Routledge.

Clients with severe dissociative symptoms tend to have more difficulty in achieving the right state of relaxation for the rewind – ie the healthy level of low arousal that enables the recoding of memories, rather than the extreme low arousal of dissociation. The eye movements of the REM state can be a useful guide. More time and attention may need to be given to helping clients establish a relaxing place in their imaginations and to re-establishing a calm frame of mind at points during the procedure as, with these clients, it is not unusual to see strong emotions, in the form of tears or pronounced facial grimaces.

Problematic molar memories can be treated in the usual way, if it is possible.8 Clients with dissociation do sometimes struggle to access an angry feeling and identify the memory it relates to (again, this can also apply in high-functioning autism) but many will be able to do so. Where a client is stalking someone, retrieving an infant memory of abandonment or rejection may pinpoint the molar memory. If a memory is preverbal, it may be more appropriate to rewind it.

Crucial, of course, is the accessing of resources which will allow clients to get their emotional needs met in more healthy and functional ways.

Our emphasis as therapists should be on enabling clients to reclaim their resources, so that, in time (and at the client’s pace), less helpful coping techniques, such as dissociation and self-harm, can begin to be safely relinquished. As part of this, building confidence by using examples of times when the person has coped well will be helpful, along with teaching better ways of reducing arousal through 7:11 breathing, aerobic activity, etc. In guided imagery, previous good coping examples can be connected to future challenges, and dealing with those challenges effectively can be rehearsed.

Keeping it simple

Armed with a clear understanding of the mechanisms behind dissociation, along with the many evidence-based methods we have in our toolbox, and our regular experience of the power of human beings to heal from even the most extreme challenges, human givens practitioners should be well placed to help people with these problems achieve significantly improved lives. Clients with dissociation – particularly those given labels such as borderline personality disorder, complex PTSD, or dissociative identity disorder – are among the most symptomatic and yet widely misunderstood people in the mental health system, and so developing expertise in treating these clients could help relieve a great burden of suffering.

However, as this client group is likely to need more than brief therapy, therapists must be sure that they have the expertise, support and spare capacity to undertake this, as well as high personal resilience.


Working with more complex forms of PTSD: important provisos

WHEN I (Emily) was an occupational therapist in the NHS, I worked for some years with adults who had experienced deep emotional damage, as a result of severe childhood trauma. So, once in private practice as a human givens therapist, I recognised the signs when Reese was referred to me by another therapist, who felt out of her depth. She had seen him for one session, ostensibly to help him with a social phobia, and had been taken aback to find that relaxing him deeply and guiding him to experience being safe in a calm place instead led him to become upset and tearful, then angry and highly suspicious of her motives. Reese, 42, had not worked for many years, and lived on benefits with his partner and two children in a damp and dingy council flat. He was extremely isolated, the anxiety he experienced preventing him from venturing out much, and he had often self-injured and made suicide attempts.

Emotional abuse and neglect from an early age had left normal rapport-building skills undeveloped. His relationship with his partner was strained and, while he loved his children and did have a connection with them, he found it a huge effort to be with them and respond to their needs. When we, on one occasion, invited Reese’s partner into a session, I learned that the children experienced him as emotionally unavailable. He found it difficult to relate to me for a long time, often stumbling over my name because his shame about himself was so intense that he felt he didn’t have a right to address other people. His main social connections came via internet chat rooms.

I knew that, if he chose to continue it, the work would be slow and improvements tiny. Indeed, I saw him weekly for a year, fortnightly for another year, and then monthly for two years afterwards. In the early sessions, I focused on psychoeducation (for instance, explaining the fight-or-flight response), taught him 7:11 breathing and introduced him to cognitive approaches to turning around negative thinking, such as the distraction technique of counting back, for 20 seconds, from 100 in threes or mentally listing the last 10 people met. I find this technique particularly useful for helping highly emotionally aroused people to disengage from negative thoughts.

Reese’s main goal was to return to paid work and so we agreed very small goals geared towards this, such as walking in the street for a few minutes, answering the phone and, further down the line, making phone calls, all of which he found stressful. We rehearsed these goals but, at this stage, much was done through role-play rather than in guided imagery – for instance, answering the telephone or meeting someone new, with me taking the part of the caller or new person. We agreed on small homework tasks each session, based on whatever we had done.

Reese engaged well with all this in the sessions and always left feeling better. But, as I expected, the effects didn’t last and, very often, he didn’t complete his homework. Normally, if this happens a lot, as human givens therapists we may decline to go further and invite the client to get back in touch when they have completed the goal that they agreed to. In my experience, this is unlikely to be the right approach with highly vulnerable clients like Reese, as it can knock their confidence even more and confirm their feelings of being a failure. I recognised that he wanted to do the work but sometimes it just seemed to demand too much of him. Indeed, when I would ask him at the start of sessions how he had got on since I last saw him, he almost always replied that it had been a struggle.

Reese manifested most of the symptoms that are ‘clues’ to a highly traumatic ongoing childhood experience. His memory was patchy; while he had some strong, vivid memories of specific traumas, he could hardly recall anything more general about his childhood. At unexpected moments, an engaged expression would switch to a blank stare. He felt deep shame about his perceived lack of success in life and he experienced a whole variety of aches and pains, which he had had exhaustively investigated to no avail. He found it extremely difficult to identify where in his body he experienced particular sensations. He also had some obsessiveness, often associated with stalking activities – he developed an overkeen interest in a woman he was chatting to over the internet, started emailing her incessantly and talked continually at one stage about how he could meet her, even though she had made it clear that she was not interested.

My criteria for success were set low. I looked at whether Reese was turning up for every session, was engaging or talking, was willing to open up about difficult issues. I thought in terms of goals that could be met in six months or a year. In such circumstances, I think it is important to expect to be in it for the long haul, otherwise it can be extremely frustrating for the therapist. It is also important for therapy not to meander on endlessly. After six sessions with such clients, I have a ‘check in’, to find out what is working for them and what isn’t, and after how many sessions they think they might want to bring the therapy to an end (giving them an element of the control). Many may have no idea, in which case I will say, “I’m prepared to offer up to another six sessions, and review again after that”.

I do know that there were valuable outcomes from the protracted work with Reese. We did eventually manage to do some guided imagery – I found, as I often do with such clients, that doing body scans is more helpful than visualising lovely places in nature, as it helps connect them with concrete bodily sensations. We also did a rewind successfully. After a year, he had developed sufficient social skills and confidence to take on a voluntary job with a local charity, which began to meet important emotional needs for connection, achievement and status. But for a long time it was three steps forward and two steps back, with many days when he just didn’t go to his job at all. He did ‘stabilise’ to a degree and began to find some enjoyment in life, and joy with his children particularly. I took a break from therapeutic work to focus on a family commitment, at which point he appeared happy to finish therapy and I have not heard from him again since. This was after about four years of working together.

Small steps for Stuart

For over five years, I worked with another client, a young man called Stuart, who had strong dissociative and psychotic experiences. Much of my role in the early days was to support him to talk about these experiences and come to an understanding of them, to validate his thoughts and feelings (even when psychotic, his thoughts and feelings were serving a purpose) and to build his resources. I would congratulate him on whatever he had done well during what he might have seen as a terrible week, remind him of the successes achieved so far and guide him towards getting his needs met in healthier ways. I always recommend exercise of some kind, not only because it is good for general health but because, in dissociation, although the person is flooded with endorphins at the moment of collapse–feign-death, endorphin levels are low when experiencing hypervigilance and other symptoms later. Exercise helps with emotional regulation too, as it expends excess adrenalin and cortisol, which are often at soaring levels when anxiety and paranoia are present.

Stuart had almost no memory of his childhood – he had been emotionally neglected by phenomenally wealthy parents (his mother suffered severe bipolar episodes and his father was largely away on work), so he even lacked the opportunity to develop coping skills because maids and chauffeurs and cooks took care of his every practical need. In a stable period, we did do some guided imagery and managed a rewind not of the indistinct childhood but of the dreadful experiences he had had in mental hospitals. This did seem helpful.

We also role-played practical skills, such as going shopping, and skills to use in social situations. He eventually started working in an animal shelter, which he loved. Slowly he developed a sense of achievement and status, although relationships remained problematic for him. 

It is vital in this kind of work to set an extremely clear contract with the client, beyond normal practice of informing clients of the cancellation policy and getting details of a GP to contact in an emergency. It is important, in my view, for instance, to establish the maximum number of sessions to be held before a review; the name and details of someone close to the client that they would be willing for you to contact to check that they are okay after a session if, for instance, the client leaves the consulting room upset and you are concerned for their safety. Whereas this is extremely unlikely to happen in normal circumstances, especially if the session has ended with a calming, uplifting guided visualisation, the state of mind of clients who are emotionally volatile cannot be predicted at the end of a session. They might take exception to something seemingly innocuous or, if they do agree to guided imagery, may react negatively to something only obliquely related to the images conjured up.

Another time it is useful to have a person to contact is if the client emails or calls to say that they are about to self-injure or attempt suicide. If there is reason to fear that the person’s life is in danger, obviously the emergency services need to be called. But, often, the announcement of intended self-injury is a cry of distress. Of course, ultimately the therapist cannot be held responsible for self-harming behaviour and it may not be preventable.

Setting ground rules

Another point to establish is the maximum length of a session and how much, if any, email contact is permissible between times; within what period of time the therapist will undertake to respond to emails (many such clients may feel in need of instant attention); and the point at which the therapist will start to charge for appreciable time spent reading and answering them. Clearly, this needs to be approached gently and sympathetically, within the context of an already-built rapport; it is, however, an important way of providing solid ground for you both, if a client in a state of highly elevated emotions should feel rejected or exploited in any way.

Equally important to decide is where to see the client. It may well not be clear, at the outset, that a client can be seriously emotionally unstable. The therapist needs to be comfortable with their work set up or be prepared to shift to a safer one, for future appointments. I once had sessions with an extremely emotionally labile woman, sexually abused and neglected as a child, who was struggling to deal with an acrimonious divorce alongside extreme anxiety, eating disorders and self-harm. On one occasion she cancelled a session just 10 minutes beforehand, for a non-emergency. As she had details of my cancellation policy, I merely accepted this and then, at the next session, reminded her that she would have to pay for the previous unattended one. She flew into a rage and started screaming and insulting me in my own living room. I was alone at the time and it all felt extremely unsafe. I asked her to leave and she stormed out. By the next session she had calmed down, admitted she was out of order, and duly paid. I would now advise that therapists see such clients in their own homes only if they have a separate dedicated work area, such as an office, and someone else is present in the building.

Then there is the nature of the relationship that the client develops with you. Dissociation happens for a reason and, while an effective survival technique, has a deeply adverse effect on rapport-building skills and management of emotions. This will inevitably enter the client’s relationship with the therapist, either in the form of difficulty building a relationship at all (this was the case for a long time with Reese) or of over-dependency (idolising the therapist, telling them no one has ever understood them so well ever in their life, bringing flowers – then, when offence is taken over something little, rubbishing them to their face or on social media). Such clients need clear boundaries set for them straight away. So, if a client says, “You are so wonderful. I feel like we are best friends,” it is wise to say something like, “Although I’m flattered [and beware, it does feel flattering], it also feels uncomfortable. You are paying me and this arrangement is professional.” Later in the relationship, it might be possible to use this kind of disclosure as a way into exploring and reshaping their relationship-building skills by probing further to say, “I wonder where this feeling comes from … when you have felt that before … how useful it has been in previous relationships. Might there be a way of managing and expressing these intense feelings which would work better for you…?” This can provide a template for practising and role-playing relationship skills, as well as ways to self-manage big emotions.

To sum up from my experience: this is valuable work but potentially very risky for inexperienced therapists to undertake. It may well be best to put an emphasis on teaching concrete skills, and expect progress towards goals to be exceptionally slow. Therapists should have good support, good supervision from someone who understands the clientele, and spare capacity within their own lives to take such work on. Finally, as the work can be lengthy, therapists need to think realistically about costs and whether they can afford to see people long-term at a reduced rate (as I did with Reese), because, of course, many people in the most dire need do not have much money to spare.

Joe GriffinJULIE LAWRENCE is a therapist in private practice. She became interested in dissociative disorders when she first had a client with a complex form of PTSD, shortly after she qualified. She has spent the last few years learning more about the condition and connecting the features of dissociative problems back to the core human givens organising ideas. In addition to practising psychotherapy part time, Julie has a leadership role in government and is a member of the HGI Board.

Joe GriffinEMILY GAJEWSKI has worked for over 21 years as a therapist in the NHS (and privately), helping people move on from even the most severe and enduring emotional difficulties in a wide range of settings, ranging from psychiatric Intensive Care Units to supporting people in their own homes. For many years she was employed as a Lead Occupational Therapist in Sussex where she developed a number of mental health services, working with a wide range of emotional difficulties (including self-harm and psychosis) and also leading on staff development and training. She now works freelance as a therapist, trainer and coach.

 


These articles first appeared in "Human Givens Journal" Volume 23 - No. 6: 2016

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References

  1. Porges, S W (2001). The polyvagal theory: phylogenetic substrates of a social nervous system. International Journal of Psychophysiology, 42, 123–146. The Wikipedia entry on polyvagal theory is accurate and easier to read: see https://en.wikipedia.org/wiki/Polyvagal.
  2. The term freeze is descriptive of the condition but as there is also an initial freeze state during the flight-or-flight response, mediated by a different defence system, the use of this term is potentially confusing.
  3. Weinstein, A D (2016). Prenatal Development and Parents’ Lived Experiences: how early events shape our psychophysiology and relationships. Norton, New York.
  4. Griffin, J (2006). Molar memories. Human Givens, 13, 3, 9–18.
  5. See Griffin, J and Tyrrell, I (2011). Godhead: the brain’s big bang. HG Publishing, East Sussex.
  6. See, for instance, Levine, P (1997). Waking the Tiger healing trauma – the innate capacity to transform overwhelming experiences. North Atlantic Books, USA; Minton, K, Ogden, P and Pain, C (2006 ). Trauma and the Body: a sensorimotor approach to psychotherapy. Norton; Rothschild, B (2000), The Body Remembers: the psychophysiology of trauma and trauma treatment. Norton.
  7. The Dissociative Experiences Scale has 28 questions and is available free on the internet.
  8. Molar memories: a protocol. Human Givens, 2008, 15, 3, 8–9.

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