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>The therapist as an affect overload container

>When working with a traumatised client the therapist acts as a “container for affect overload” (Wilson et. al 2004) to contain the out-of-control effects of trauma re-awakening on the client. This means acting without judgment or shame while continuing to maintain boundaries even as the client is acting out in front of him. Some of the more severe reactions that may be experienced by the clients include traumatic regression, re-enactment and flashbacks. Such abreaction states in a client can seem overwhelming which may leave the therapist feeling helpless. Alternatively, the client may retreat to a “closed dysphoric affect state” where numbness and dissociative states prevail. While in this state, the client may be unreachable and this again could render the therapist feeling shut off and powerless. According to Wilson et. al, while the reenactments of the trauma can be quickly reeneacted in the therapy room, effective work on the trauma cannot be done until it has been effectively understood, accepted and contained.

If the client has reacted with out-of-control reactions, this will be accompanied by shame of the leaking out of these affect overload. The client has to feel that the therapist understands the discomfort at the out-of-control feelings without adding to the shame the client already feels. When the client is sufficiently composed, the task is to piece back what had led to the affect overload. However when the client is closed down and numb, the therapist has to patiently wait and maintain a safe environment which serves to reassure the client. Numbing serves as a defence against affect overload which can take up a lot of the client’s energy to maintain and can only be overcome when the client feels safe and ready. Clients who experience trauma often have lost or never developed any self-soothing mechanisms. \the therapist’s function in calmly holding the therapeutic space and conveying empathy can serve to help the clients develop this ability in themselves.
In addition to these common affects, traumatised clients can experience a fractured sense of identity which can lead to a chaotic state of being. This can lead to a mistrust of the world which is seen as unreliable and this could also include the therapist. As the relationship progresses, there may be points where the need in the client for an idealised object to hold onto may lead to idealisation of the therapist. Conversely disappointment and mistrust of the ability of the therapist to understand can lead to rejection of the therapist. Both patterns may play out in cycles throughout the therapeutic relationship through the transference/countertransference process while the client moves from various points in revaluating the trauma.
The therapist functions as a reparative idealised mother-object for the traumastised client. However this transference may be beset with more negative resonances in its development. In writing about childhood trauma Carpy (1987) speaks of the impulse to blame is present in everyone as it arises from the most primitive psychotic states. In a traumatised client, a sense of grievance has to be maintained in an active state to protect the client from an awareness of actual dependency on the less than ideal object. In the present, any triggers related to the trauma may bring about a fresh accumulation to this feeling of grievance which then may be directed strongly at the therapist.
To work successfully through the trauma, the client has to be into a process of mourning the loss of the idealised object. However, the success and pace of this may be dependent on external circumstances such as historical and societal factors and the internal factors such as the client’s own psychological history.(Garland 1991).  The therapist’s task is to maintain the container for the client’s affect breakthrough and working out during this process while facilitating the development of de-alienating the past from the present.  In doing so, the effects on the therapist experiencing with the client the unbrearable effects of remembering and reenactment may also prove unbearable to the therapist own ego.
References
Carpy, D. (1987). Fantasy and reality in childhood trauma: who’s to blame?’. Tavistock Paper No. 64B.
Garland, C. (2004). Understanding trauma: a psychoanalytical approach. Karnac Books.
Wilson, J. P., Friedman, M. J., & Lindy, J. D. (2004). Treating Psychological Trauma and Ptsd (1st ed.). Guilford Press.

>Neurobiological responses to trauma and its memory

>The limbic system acts as the emotional thermometer which reacts environmental stimuli to assess whether it rewards or threats the individual. This system is made up of several regions in the brain including the amygdala, hippocampus,hypothalamus  and the frontal cortex. The amygdala and hippocampus are the two parts of the brain are essentially involved in response to, and memory of, traumatic events (See van der Kolk 1994, Nadel & Jacobs 1996, Levine1997).  The amygdala regulates regulates emotion and the hippocampus attaches emotional significance to experiences. Other parts of the limbic system regulates biological needs though the hypothalamus and the frontal cortex is responsible conscious thinking and emotions.

The Limbic System responds to extreme traumatic threat, in part, by releasing the stress hormones cortisol and adrenaline. This prepares the body for fight or flight. Th Sympathetic Nervous Systems prepares the body  through increasing respiration and heart rate to provide more oxygen, sending blood away from the skin and into the muscles for quick movement. In certain 
circumstances however, the Limbic system can simultaneously release hormones to activate the Parasympargetic Nervous System and a state of freezing can result (Gallup 1977, Levine1997). These circumstances are when there is not time or strength to fight and death may be imminent or when the traumatic threat is prolonged.. In this freezing state, the individual feels no pain enters an altered reality where time slows down. This is a form of dissociation which could have evolved in animals to contribute to a the chances of survival as the attacker (i.e. a cat) would lose interest in a stiffened prey (i.e. a lifeless mouse) These nervous system responses – fight, flight and freeze – are survival reflexes
There is growing belief that the amygdala is involved in storing these highly charged emotionial states. The other part of the brain, the hippocampus stores memory in a contextual form. This includes placing past events in its rightful place. However it is believed that when traumatic events happens, the hippocampus is supress and the temporal timestamp function of the hippocampus is prevented from happening. The traumatic memory becomes something that has the potential to seep into the present.

A term coined by Goleman (1997) is “Amygdala Hijack” which refers to the reactive tracking of a response through the amygdala rather than through the cortex. People with a history of trauma often have often have heightened reactivity and impulsivity around anger and fear. Life-threatening situations result in the permanent imprinting of the experience in the emotional circuits through the amygdala. Associated cues are stored through the declarative memory circuits involving the hippocampus which captures the emotional experience of the trauma.  These associated cues  can trigger the emotional memory of trauma thus bringing it to conscious awareness. For instance, a person who has been traumatised in war zone situations may be triggered by everyday explosive sounds such of a car tyre bursting. The sounds could trigger flashback with images and emotional reactions such as fear.


In psychodymanic theory, Bohleber(2007) aruges that the intensive exciatation increases the remberance of key features of the event atlough the unconnected details may not be. He argues that the ego has to be able to mantain the its observational function wherease in severe trauma this function breaks down. Memory can become fragemented.  With traumatic memories, the present can only perceive and structure the past in a limited way. When traumatic events are retained, the facts not the psychic reality of the inner experience are remembered.

With this limited evidence what I begin to see is the argument that storage and recall of traumatic memories are perceived to be different than the normal memories both in terms of neurobiological and psychological processes.


>Repetition complusion

>

In pyschodynamic theory, the individual’s drive to obtain mastery over the feelings of distress associated with traumatic material is through repetition-compulsion. Repetition complusion is an instinctual drive that propels inividuals to reneact experiences and is synonymous with the ‘death instinct’. This counter intuitive complusion to repeat the distress goes against the pleasure seeking drive of what Freud termed ‘the pleasure principle’. The death drive describes the drive towards death and inorganic state as in death ultimately all tensions are released.
In “New Introductory Lectures to Psychoanalysis” (1933/32), Freud wrote, “And now the instincts we believe in divide themselves into two groups—the erotic instincts, which seek to combine more and more living substance into ever greater unities, and the death instincts, which oppose this effort and lead what is living back into an inorganic state. From the concurrent and opposing action of these two proceed the phenomena of life which are brought to an end by death”. 
To successfully process the material at the point of trauma an individuals has to have a balanced ego defence system with sufficient ego resources to process the traumatic material. Those with maladaptive ego systems, individuals are more likely unable to ameliorate the effects of the trauma and carry on to develop conditions such as PTSD. As such, there is a great possibility that these factors also play a part in a therapist’s predisposition to suffer from vicarious trauma

>Freud’s Seduction theory

>Freud’s seduction theory was a powerful hypothesis for the time. He concluded that a premature sexual contact or a traumatic sexual event must have been experienced by ‘hysterical’ patients he saw who all were displaying the same symptoms. His findings were very much inline with what Charcot, his teacher also saw similar symptoms in his ‘hysterical’ patients. His seduction theory was one of the first real recognition of the possibility of sexual abuse and the traumatic effects following such an experience in childhood. The related papers on the topic were  “Heredity and the Aetiology of the Neuroses, Further Remarks on the Neuro-Psychoses of Defence” and  “The Aetiology of Hysteria “. Freud presented Aetiology to the Vienna Society for Psychiatry and Neurology at the end of April 1896. His theories were met with disbelief and hostility.

Although at the time he believed the patients were telling the truth about actual traumatic events, he later wondered if he had put undue influence on them. Freud abandoned the seduction theory in a letter to William Fleiss in 1897. He concluded that the reported experiences of his patients were remnants of infantile sexual fantasies.Modern commentators such as Herman and Rush argued that he was wrong to abandon this theory and was probably influenced by the cultural pressures of the time. With the abandonment of the seduction theory, the concept fantasy developed into an important aspect of psychoanalytical theory and Freud rejected the direct causal relationship between trauma and its effects.


A parallel development was the concept of Nachträglichkeit  (loosely translated as deferred action), Freud postulated that  the idea that an event in the past could be reactivated in the individual by a later event . For Freud trauma is the interaction between these two events This was psychic trauma: that of the original event which leaves its trace and that of the event’s later revival by an internal factor at a time when deferred understanding and interpretation is possible ( for instance with sexual maturity).. In speaking of the nature of ‘remembering’ and ‘forgetting’, Freud remarked on the unreliability of memories which are influenced by the unconscious meanings attached to the memories.


I am left wondering perhaps if the Nachträglichkeit  concept could also be applied to vicarious traumatisation where the after effect of the client’s material on a counsellor revives some repressed meaning which is attached to a previous trauma? More to be read and discovered later..

>Trauma and the human existence – Intersubjectivity and attunement

>In this book Robert Stolorow examines trauma in relation to the contextuality of human life and the particular experience of trauma. Although he concentrates mainly on ’emotional trauma’ the discussion also focuses on the impact of a traumatic event has on an individual. In particular he speaks of the impact of his wife’s Dede’s death had on him and his son. As Stolorow draws upon the psychoanalytical tradition, he also uses the term analyst and patient which I will substitute for counsellor and client.

Stolorow draws upon the intersubjective work of himself, George Atwood and Donna Orange. He argues that the Cartesian “myth of the isolated mind” (Stolorow and Atwood 1992) describes a subjective world divided into inner and outer regions. In the intersubjective system theory the shift is towards a phenomenological contextualism (Orange, Atwood & Stolorow 1997) and a focus on the intersubjective field (Stolorow 1997). It is a relational system where psychological conflict stems from unintegrated affect states which threaten psychological stability and relational ties. Developmental trauma stems from childhood malatunement from caregivers result in disruption of affect integration. This results in disorganised and unbrearable state in the child due to the loss of affect integration capacity. Defenses develop such as a idealised self which is a purified ideal necessary for self-esteem and maintaining ties to others.Emotional experiencing also narrows to exclude unacceptable feelings.

Therapeutic impact is not only made through analytical interpertations but in the attunement of the counsellor towards the client. Qualities in the counsellor that might be met with transference expectations in the client that his feeling states will be met negatively. The emotional bond between client and counsellor is not a separate entity but is a crucial part of the relational process. The bond has to withstand the extreme affect states that accompany the cycles of re-organisation and destabilisation in the therapeutic relationship.Misattunement by the counsellor can result in retraumatization as trauma is formed in an intersubjective context as the painful emotions cannot find a “relational home ” (p.10)

What I find interesting is that although Stolorow agrees with Krystal (1978) that trauma is the experience of unbearable affect, he emphasizes that the intolerance of affect state does not depend in the scale of the painful feelings evoked. It is the failure of attunement and responsiveness to the affect states that makes them endurable resulting in these states becoming a source for trauma and psychopathology. Additionally, Stolorow  believes this is true for one-off traumatic events and cumulative traumas (Khan, 1963).

With regards to VT, cumulative effect of the traumatic material on the therapist is one of the factors elading to VT. I am not sure yet where this thread is going but I hope to follow it up soon.

>Mercy and Grace

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This is a blog of I started as part of  my literature review of Trauma and Vicarious Trauma. I hope some of the points of discussion will be useful for those who are interested in this topic. I am not claiming to be an expert but hope will share my learning (and mistakes!) with anyone reading this blog.

As a female Muslim of Asian origins I am aware that my own gender and cultural background will influence how I will see the material that is written about this area. I start this blog with the opening phrase from the Quran which means “In the name of Allah the Most Gracious and Most Merciful”. As trauma touches on aspects of death and the anxiety surrounding it, this will inevitably bring up discussions of how the individual perceives these issues if not in religious terms, at least in philosophical terms. As I am unfamiliar with Western philosophy, this blog will also include my learning journey on this subject.

The title of the blog is a two part reference. ‘Authentic’ refers the congruency in the counsellor which is part of the Carl Rogers ‘Core Conditions’. The second part ‘Attendance’ refers the counsellor being a witness and attendant to the to the client. Specifically in this case, as a witness to the trauma experienced by the client. Orange (1975) and Miller(1990) speaks of the trauma being validated to enable it to seem ‘real’  to the individual who is traumatized. In witnessing trauma, a counsellor plays an important part in helping the client make sense of the traumatic experience but this can also leave a profound and lasting impact on the counsellor herself. It is hoped that thus blog will be able to look at the different aspects of this impact on the counsellor. I will include any references to papers, books, websites and other references as I come along. I hope that this blog will be an interesting and educational discussion on the topic and welcome any constructive contributions to the subject.

Thank You