Working with more complex forms of PTSD: important provisos
Emily Gajewski shares her case experience with working with more complex forms of PTSD
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.
This article first appeared in "Human Givens Journal" Volume 23 - No. 2: 2016
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