1. Affect-Based and Relational Healing Approaches to Complex Trauma Christine A. Courtois, Ph.D. Psychologist, Independent Practice Washington, DC cacourtoisphd@aol.com www.drchriscourtois.com

2. Interpersonal Trauma: “A break in the human lifeline” Robert Lifton Self and interpersonal effects brought to treatment

3. Relational Healing for Relational/Interpersonal Injury

4. RICH relationship/Risking Connection n Trauma-oriented approach involving: u Respect u Information u Connection u Hope (Saakvitne et al.)

5. Interpersonal Neurobiology -- Right brain to right brain attunement: implicit factors --Development of new neuronal pathways: “neurons that fire together wire together” connection enables genetic expression --“Earned secure” attachment through relationship

6. Psychotherapy is a “shared journey of inescapable mutual influence” (Schultz-Ross, Goldman, & Gutheil, 1992)

7. Response to Trauma is Impacted by Objective and Subjective Factors (Wilson, 1989) n Objective u details of the experience and how it happened n Subjective u the individual’s unique experience of the situation Therapist must seek to understand the unique circumstance and meaning

8. Transference and countertransference... “traditionally refer to the reciprocal impact that the patient and the therapist have on each other during the course of psychotherapy. In the treatment of PTSD …, the transference process may be trauma-specific…and/or generic in nature, originating from pre- traumatic, life course development as well as from traumatic events.” (Wilson & Lindy, 1994) therefore, transference/countertransference reactions can be compounded by trauma

9. Attachment Patterns Resulting from Interpersonal Trauma that Might Play Out in the Therapeutic Relationship* n Secure n Insecure: anxious-fearful (vigilant) u Dependent (“velcro”) u Avoidant u Self-defeating u With borderline characteristics {per the work of Bowlby, Ainsworth, Main and colleagues; Alexander & Anderson (1994); DeZulueta (1993); and Liotti (1992,1993) applied to PTSD/DD’s}

10. Attachment Patterns Resulting from Interpersonal Trauma that Might Play Out in the Therapeutic Relationship (con’t) n Insecure: Anxious-avoidant (dismissive) u Counterdependent/self-sufficient (“teflon”) u Detached u Dissociated (Barach, 1991) n Insecure: Disorganized/disoriented u Avoidant, self-defeating, borderline highest likelihood u Contradictory, approach/avoid; push-pull style u Dissociated (Liotti, 1992; 1993) u By age 6, often involves a sub-style of controlling/caretaking

11. Object Relations Defenses n Purpose: To preserve the object, the self, and the attachment n Primary defenses include: u Idealizing/devaluing u Splitting of self and object u Identifying with the aggressor (In Blizard & Bluhm, 1995, quoting the work of Masterson, 1976, 1981)

12. PTSD/DD Defenses n Purpose: To avoid experiencing trauma memories, responses and emotions (pain, overwhelming emotions, and feelings of powerlessness). n Involves ego splitting and/or creation of new ego states (through splitting of consciousness and awareness via dissociation) to project and contain disavowed and unacceptable feelings, impulses, or objects.

13. The Three R’s: Reenactment, Repetition Compulsion, and Revictimization n Abused individuals may play out what they “know” implicitly, giving clues to their history u In relationships in general F intimate F parenting F work u In the therapeutic relationship F transference F enactments, reenactments, projective identification u May give somatic/behavioral/relational (vs. narrative) clues especially in response to triggers or feelings NB: the therapist must beware of interpreting too literally or overinterpreting, especially when memories are unclear

14. The Therapy Relational Matrix Posttraumatic Involving one or a combination of re- enactment, re-experiencing, and re- victimization phenomena and alterations between numbing/denial and intrusion symptoms along with hyperarousal and startle responses. (Loewenstein, 1993)

15. The Therapy Relational Matrix Dissociative Involving such properties as absorption, heightened suggestibility, focused attention, and amnesia; altered perceptions; and cognitive distortions such as literalness and the tolerance and rationalization of illogic and contradiction (trance logic). (Loewenstein, 1993)

16. Relationship with the Patient n transference/countertransference n therapeutic alliance n real relationship Non-countertransference (but may be affected by countertransference): n positive attitude n warm, connected stance n responsive/interactive n compassionate n empathic n appropriate and empathic confrontation n interpretation (adapted from Turkus, 1993) (adapted from Turkus, 1993)

17. The Therapeutic Relationship n Need for empathy n Need for attunement n Misattunement is an opportunity for repair u u When ruptures occur (as they always will), the therapist uses the opportunity for communication and problem- solving leading to repair F F owns mistakes F F shares feelings in the moment (with discretion) F F is not blaming F F seeks to understand, collaborate u u Therapist must not make self the “all-knowing authority on high”

18. Boundary Issues n n Potential for boundary violations (vs. crossings) common with this population (indiscretions, transgressions, and abuse) u u Playing out of attachment style and issues u u Playing out the roles of the Karpman triangle, plus F F victim, victimizer, rescuer, passive bystander F F potential for sado-masochistic relationship to develop u u Roles shift rapidly, especially with dissociative patients u u Must try to stay steady state

19. Boundary Issues u u Therapist must be aware of “treatment traps”, transference, countertransference issues and carefully monitor the relational process u u Therapeutic errors and lapses will occur and how they are handled can either be disastrous or can be restorative to the patient and the relationship F F knowing about them can help the therapist get out of them more rapidly and manage them with less anxiety (Chu, 1988)

20. Boundary Issues n n Safety of the therapeutic relationship is essential to the work n n Responsibility of therapist to u u Maintain vigilance and the integrity of frame u u Be thoughtful as to setting boundaries/limits F F re: availability, personal disclosure, touch, fees, gifts, tolerance for acting out behavior, social contact, etc. u u On average, start with tighter boundaries u u Avoid dual roles wherever possible u u Be prepared to hold to boundaries/limits but also to have some flexibility u u Complete personal therapy as necessary u u Engage in ongoing continuing education, consultation/supervision, peer support

21. Boundary Issues n n Rescuing-revictimization “syndrome” u u “vicarious indulgence” as a treatment trap, especially for novice therapists and those who have a strong need to caretake or are enticed by the patient u u may give patient permission to overstep boundaries, ask for and expect too much u u may then lead to resentment/rage on the part of the therapist and abrupt, hostile termination for which the patient is blamed u u may relate to malpractice suits, in some cases (see BPD literature) n n Progression of boundary violations: the “slippery slope” e.g., from excessive disclosure to patient as confidante, excessive touch to sexual comforting and contact n n It is never OK to sexualize the relationship

22. Transference Reactions Transference reactions, projective identification, and enactments are all ways that the traumatized, dissociative patient might communicate with the therapist who must strive to be open to experiencing them, identifying them, and seeking to understand their meaning with the patient.

23. Five Selected Transference Themes in Trauma Treatment 1. Traumatic 2. Shame-Based 3. Merger-Abandonment 4. Sadomasochistic 5. Loss-Based

24. Some Traumatic Transference Reactions n May be very confusing; shifting and alternating u kaleidoscopic (Davies & Frawley, 1994) n Reenactment of Karpman Drama Triangle Plus u shifting roles of persecutor, victim, rescuer u additional role of passive bystander n Projection of abuser role on the therapist u “You will be like my abuser” u “You will use me for YOUR purposes” u “You will be gratified by my pain” u “You are venal and self-serving” u “You too will betray me, are not to be trusted, ever!”

25. Victimizer Victimizer Victim Rescuer Victim Rescuer Passive Bystander

26. Traumatic Transference Reactions n Fear of being known & fear of being re-abused u Therapy may feel like torture to the patient due to control and power dynamics F patient is “intruded upon” and made vulnerable u Patient may behave like a victim and “invite” the role of perpetrator/intruder n As compensation, perfection may be expected of the therapist--anything less is intolerable u “You must be perfect, or you are like them” u “You must take of me, love me, etc, perfectly”

27. Traumatic Transference Reactions n Erotic/eroticized transference may develop u Patient may resist or try to control/protect self through dependence/attachment/seduction u Erotic Transference: Pertaining to the need to be special, exceeding the usual boundaries of treatment u Erotized Transference: “an intense vivid, irrational, erotic preoccupation with the analyst characterized by overt, seemingly ego-syntonic demands for love and sexual fulfillment from the analyst”. (Blum, 1973) n Erotic and traumatic/dissociative transferences may cause the development of a sadomasochistic aspect to the therapy relationship (Chefetz, 1991)

28. Traumatic Transference Reactions n Patient may victimize/“torture” the therapist u Direct action: assault, threats, property destruction, self- harm, suicidality, risk-taking, stalking, intrusion into the therapist’s life F “I’ll show you what it feels like” u Restitution and entitlement dymanics F “You owe me and must make up for the past” F “You are not good enough/nothing you do is good enough” u Malignant passivity and regression F “rescue me!” u Resistance and non-cooperation with treatment contract F “I’ll prove to you how bad I am and make you give up on me”

29. Some Shame-Based Transference Reactions n Personal devaluation u “I am bad” u “Don’t notice me” u “I deserve mistreatment and neglect” u “I’m unworthy and flawed, you’re not” u “To work with me, you risk being like me” u “I’ll contaminate you” n Grandiosity as a defense u “I’m better than you and don’t need/want anything” u “Don’t see me for who I really am” u “I won’t let you in”

30. Merger-Abandonment Transference Reactions n BPD-type dynamics u Preoccupation with regulating space u Relationships are viewed as rigid, non-elastic u Attachment to defend against fear of abandonment: fusing/losing u Attachment/rejection u Longing/dread u Connect/disconnect u Idealization/devaluation u Splitting

31. Merger-Abandonment Transference Reactions n Transference bondage (Kohut) u Patient trades autonomy for safety/attachment u Reparenting dynamic u Dependence/passivity n Idealization/devaluation u “You are my savior/you are no good” n Other-directness/superficial compliance u “What is it that you want?” u “Let me take care of you because that is what I know/that is how I stay safe”

32. Sado-Masochistic Transference Reactions n Power and control dynamics u often to defend against terror, pain, and sadness u attachment/detachment through controlling or being controlled n Victim/victimizer role enactments u identification with the perpetrator u revictimization and repetitions/reenactments n Rage and pain to violence/sexualized violence n Therapist as sadist or masochist u May be abuser, bystander, rescuer, or victim

33. Loss-Based Transference Reactions n Patient often has multiple losses to grieve u Of self, lifetime, personal development u Exploitation and betrayal u Lack of protection, neglect, abandonment u Reenactments and other behaviors/reactions n Losses may be denied u Anger may mask grief u Patient may defend against the painful affects associated with losses and resist attempts to work with them n Abandonment may be expected/feared u patient may expect no empathy and abandonment if losses are acknowledged n Losses may continue in the present, sometimes due to the effectiveness of treatment

34. Countertransference n Always present, so expect it!!! n Consider it a valuable source of information u Seek to talk about it u Seek to explore and understand it F alone, in consultation and supervision F with the patient u When caught in enactments, try to use them to understand the patient. Maintain therapeutic boundaries!!! Be aware of personal limitations and vulnerabilities. Seek consultation as needed

35. Factors That Interact to Determine Countertransference n The nature of stressor in the event and recounting n Personal factors in the therapist n Patient factors relevant to understanding countertransference n Institutional/organizational/societal factors

36. Countertransference Indicators n Physiological and physical reactions n Emotional reactions n Psychological reactions n Signs and symptoms that may be conscious or unconscious: u forgetting, attention lapses u loss of empathy u anger, hostility u relief when appointment is missed u denial of feelings or need for consultation u excessive concern u psychic numbing u self-medication u loss of boundaries (Wilson & Lindy, 1994)

37. Common Countertransference Reactions in Trauma Treatment n n Fascination, overinvolvement n n Disbelief, denial, underinvolvement n n Horror, disgust, fear n n Shame, guilt n n Anger, rage, irritation n n Sadness, sorrow, grief n n Powerlessness, overwhelmed, exhausted n n Incompetence, de-skilled, confusion n n Sexualization, voyeurism, exploitation, sadomasochism n n Difficulty with boundaries and limits

38. Countertransference Categories in Trauma Treatment n Type I: Avoidance, detachment u empathic withdrawal/empathic repression n Type II: Attraction, overidentification u empathic disequilibrium/empathic enmeshment n Type III: Aggression, hatred, exploitation u absence of empathy