Margaret Landale ran a Brighton Therapy Partnership training course in November 2016 on how to work with trauma, and how powerful the therapeutic relationship can be in providing a space where a client can begin to feel safe to process the trauma. We’ve condensed some of the takeaways for those who couldn’t make it to help you work with trauma in your own practice.
What is Trauma?
Trauma was considered a mental illness until the 1980s. It was only then that the experiences of survivors of the Vietnam War led to comprehensive research into the neurobiology of trauma. Peter Levine (2008, p8) refers to trauma as a “highly active stress response frozen in time”.
Trauma occurs when a person has experienced high quantities of stress without the ability to escape or move through the stress response. This means that the threat response stays frozen in the person. If the threat is severe, repetitive or ongoing then this could lead to Post Traumatic Stress Disorder (PTSD), and often this arises when the person does not go through the realisation that the threat has now passed.
The relationship between trauma and attachment
Our ability to come through a severe threat response is grounded in our early attachment relationships, and how the person learnt to manage stress as a baby/child. If the caregiving environment is ‘good enough’, the child can learn that bad things happen, but they can get through them with the support of caregivers. However, if this attachment has been interrupted, it can be very difficult for a person to move through the stress response, meaning that they may find it hard to realise that the threat has now passed.
Complex PTSD may arise when a person has not benefited from ‘good enough’ care giving in childhood. They may have not leant how to regulate their stress responses, and may lack an internal sense of safety. When this person experiences threat, which is severe, repetitive or on-going, they are likely to develop complex PTSD symptoms such as:
- Dissociation (disconnection from emotions)
- Somatisation (unexplained physical problems)
- Negative self-belief (beliefs such as “it is my fault” or “I am bad”)
- Shame responses
- Self harm
Working with trauma in the therapy room
Working with a client suffering from trauma relies on the therapist first examining their environment and their own attitudes and mindset when approaching the client. Only then can the therapist begin to work through the processes required to deal with the client’s trauma.
Understanding the relational environment
Complex PTSD is embedded in the relational environment. This means that, for a survivor of trauma, the therapeutic relationship is a similar environment to where the survivor may have been harmed in the first place. This gives the therapeutic relationship the potential to ignite huge quantities of stress within the survivor. It is quite possible that on some level, they will be experiencing high levels of PTSD symptoms when they arrive in the therapy room.
If the therapist is attuned, then they may be pulled into the ‘extra empathy’ stance, leaning forward and being drawn to rescue the client. The therapist may be pulled to make a lot of ‘useful’ interventions in attempt to find meaning for the client. Ultimately, this kind of intervention can repeat the pattern of disempowerment of the survivor.
The therapist’s response to symptoms of trauma
If the client arrives in the therapy room in the stress response, it is easy for the therapist to pick this up and feel some of this trauma response. If the client is in ‘hyper-arousal’, the therapist might begin to feel some of the symptoms of this, such as a racing heart, and shallow breathing. Alternatively, if the client is in ‘hypo-arousal’ the therapist may reflect this by feeling sleepy, or switched off. In order to provide a therapeutic environment for a trauma survivor, the therapist needs to learn how to regulate her stress response in the relationship with the client.
Margaret suggested some exercises for the therapist to begin to pay attention to her bodily experience and become grounded in the here-and-now. It can be helpful to breath deeply and focus on the breath to bring oneself back to the here-and-now.
It can also be helpful to identify an ‘anchor’. This can be kinaesthetic (feeling the sense of being seated in the chair), using the breath, focusing on the auditory experience, or finding somewhere visual to focus. This helps to bring the focus back to the embodied here-and-now experience.
Using mindfulness within the session can help the therapist to regulate her own somatic, emotional and mental processes in the relationship and this will help to create a quality in the relationship which may feel like the ‘base security’ that was lacking in the client’s early attachment relationships.
Building trust between the client and therapist
Once the therapist can provide the experience of an emotionally grounded and present ‘other’ for the client, the trust and safety can build up. It is only then that the client may feel safe enough to explore their physical responses to the trauma.
Margaret suggested a “bottom-up” approach. This means being lead by the clients embodied felt experience of the trauma and asking the client to describe their experience – paying attention to the sensations and experiences that arise. It is important to treat each minutiae of the client’s experience as important. This means that the therapist needs to lose her intention to ‘make sense of the trauma’ for the client; rather she gives the client the choice to explore her direct here-and-now experience. If this happens in the therapeutic relationship, it may be possible to begin to process the trauma.
Margaret suggesting using a phenomenological approach when working with a survivor of trauma. She asked us to consider the following:
- bracketing – not making assumptions or objectifying the client
- focusing on description – using description as a form of investigation/enquiry)
- horizontalisation – the therapist uses observation without the attempt to join the dots. The therapist helps the client to just notice what arises without trying to find the meaning. This is where insights may emerge for the client.
- the therapist is curious
The therapist may give the client psychological information so that the client can join the therapist as their own core trauma expert. The therapist will help the client to identify her resources, and where she might need better resources. In this stage, the therapist is helping the client to know what it feels like to feel safe.
Processing and integration
When the therapist and client have built a grounded and safe relationship and the trauma has been acknowledged, the client may begin to feel able to process the trauma.
This happens when the client knows that she is ready. The therapist attunes to the client and helps her to use her resources to stay with the phenomena of the process. It is only in a safe therapeutic relationship that the client can then begin to integrate; making gentle physical, mental and emotional changes. These can be guided by imagination and metaphor.
The therapist must create a safe space
To conclude, to work with trauma therapeutically, the therapist needs to be grounded in herself, in order to be able to create a safe space for the client. Mindfulness is an excellent practice for counsellors to learn to be more attuned to themselves or others. Only then can trust be built between the therapist and the client, and the process of healing trauma can begin.
Levine, P., (2008) Healing Trauma. Boulder: Sounds True. Available to buy here: