Derailed

related disorders suggests that relational issues must have a central role in the psychotherapy of these disorders. The resolution of relational issues is at the heart of most phase-oriented models of trauma treatment and is described at length in the subsequent chapters of this book as well as by other authors (see, for example, Courtois, Ford, & Cloitre, 2009; Herman, 1992b; Lebowitz, Harvey, & Herman, 1993; Steele, Van der Hart, & Nijenhuis, 2001). However, several models of psychotherapy for trauma-related disorders explicitly focus on disordered attachment as the essential part of the treatment process. In his 2000 book, Not Trauma Alone: Therapy for Child Abuse Survivors in Family and Social Context, psychologist Steven N. Gold, PhD, describes his model of Contextual Therapy. Rather than having a simplistic focus on trauma processing, the model emphasizes building collaboration (especially in the therapeutic alliance), correcting maladaptive negative beliefs about the self (e.g., being unworthy of and incapable of sustaining relationships), and learning skills to reduce symptomatology and enhance interpersonal ties. In a 2001 paper, Gold and colleagues describe three cases of considerable complexity where unexpectedly rapid progress was achieved by leading with a focus on building relational capacities, which then facilitated the resolution of posttraumatic and dissociative symptoms.

In a 2001 paper, psychologist Ruth Blizard, PhD, highlighted the relational issues of disorganized attachment in persons who grew up with abusive primary caretakers, leading to dissociated victim/masochistic and perpetrator/sadistic ego states. Her treatment model is focused on understanding the defensive structure of ego states and ameliorating the relational conflicts between them:

When alternating ego states are understood as evolving from defensive schemas developed to negotiate the dilemmas of attachment to an abuser, the following therapeutic techniques can be derived: 1. identifying adaptive needs and maladaptive defenses, 2. interpreting ego state switches as attempts to resolve relational dilemmas, 3. gradually bridging dissociation between states, 4. using transference and countertransference to understand relational patterns, and 5. cultivating more adaptive interpersonal skills within the therapeutic relationship. (p. 37)

Issues related to attachment and traumatization must be interwoven into the therapy. One of the more important ways of encouraging a positive therapeutic attachment and developing a sense of alliance is for therapists to validate the essential elements of patients’ abuse. Whereas an earlier generation of psychoanalytically oriented therapists may have been concerned about the symbolic distortions of such retrospective accounts of abuse, it is now clear that such accounts can often be corroborated (Chu et al., 1999; Feldman-Summers & Pope, 1994; Herman & Harvey, 1997; Herman & Schatzhow, 1987; Kluft, 1995). A reflexively skeptical response is likely to appear hostile and will almost certainly damage the fragile therapeutic alliance. Therapists who focus only on the intrapsychic conflicts produced by past abuse or on possible distortions of initial accounts of abuse are guilty of empathic failure. Such stances tend to devalue patients’ perceptions of their experiences, resulting in increasing their sense of shame and fearfulness within the therapy or even precipitating flight from therapy. This is not to suggest that therapists should encourage patients to believe in the literal truth of all recollections (including those that may be poorly or hazily remembered) or to conjecture about what might have happened. Similarly, therapists should not conclude that all borderline patients, or all patients with certain behaviors or traits, have been subject to gross abuse. Rather, when appropriate, therapists can ally with their patients’ sense of having been victimized, which can help these patients to begin to understand their own feelings and behaviors.

Acknowledgment of the reality of past victimization is also helpful when coping with issues concerning therapeutic responsibility. Most patients with histories of abuse are typically burdened by undue feelings of responsibility for their having been victimized or abandoned. The coping strategies and defenses characteristic of traumatized patients make them particularly likely to take flight or to become defensively angry in response to interventions that emphasize their being responsible for creating their own problems. It is necessary to help patients distinguish clearly between the need to take responsibility for caring for themselves in the present and wrongly assuming the responsibility and blame for having been abused in the past.

An approach that emphasizes the importance of empathizing with patients’ abuse experiences and their adaptation to such experiences mandates alteration of traditional therapeutic interventions. For example, interpretations concerning the centrality of anger in the patient’s life or pointing out the manipulativeness of patients’ actions are often counterproductive early in the therapy. These types of interventions may ask patients to “own” their angry feelings and behavior before validating the reasons why they are angry or behave in dysfunctional ways. Such approaches may be especially likely to evoke negative therapeutic reactions in traumatized patients with borderline characteristics (Adler, 1985; Brandchaft & Stolorow, 1987; Kolb & Gunderson, 1990). Indeed, premature confrontations and interpretations have been shown to be a major cause of borderline patients dropping out of therapy (Gundersonet et al., 1989). Interpretations that identify a patient’s angry motives and feelings usually need to be accompanied by empathy and validation of past trauma. For example, the therapist could convey that the patient’s anger about past abuse is understandable, but that angry feelings must be identified and expressed in a manageable fashion.

Reports of successfully treated patients have documented the importance of support and the significance of patients developing a positive attachment to the therapist (Waldinger & Gunderson, 1987; Wallerstein, 1986). Early interventions are most successful when behaviors (including even those that may be dysfunctional, such as self-destructive behavior or flight) are understood and reframed as being understandable, sometimes even admirable, adaptations to childhood experiences, but the behaviors are misplaced and no longer useful in the present. More generally, whereas virtually all patients must make a personal commitment to their own self-care before they can work as allies in treatment, those with histories of severe abuse require added support during the early phases of treatment, gentleness about interpretations directed at their traumas, and patience about expecting them to engage in stable therapeutic alliances or to do transference-based work.

Establishing and maintaining a positive therapeutic alliance is critical throughout the treatment of traumatized patients and begins the healing process for disordered attachment. Of course, validation of trauma and other supportive interventions are only the first step in the treatment of traumatized patients, as empathy and understanding alone can result in patients becoming mired in a chronically victimized and helpless position. As the therapy continues, ongoing efforts to maintain a sense of engagement must be supplemented by interpretations and confrontation (e.g., around dysfunctional behaviors and dissociated affects such as hate and aggression). However, an ongoing effective alliance and an empathic sense of the traumatic antecedents of patient’s feelings and behaviors will make such interventions more acceptable. Establishing empathic resonance before interpretation or confrontation is essential (Chu, 1992a). As Mann (1973) noted,

[T]he gentle, caring concern of the therapist for the patient may well be the most important element in a proper, effective confrontation.… It communicates to the patient his privilege to choose the direction that he would like to move in rather than communicating a directive to which the patient feels impelled to yield. (p. 44)

1 This is exactly the same dilemma that the abused child faces in the models of Shengold’s “soul murder,” Summit’s “child sexual abuse accommodation syndrome,” and Freyd’s “betrayal trauma” as discussed in Chapter 1.

2 Russell’s paper was originally presented at the Massachusetts Mental Health Center, c. 1970. It was unpublished but widely circulated in the mental health community for many years. Along with several other papers that memorialize Russell’s wisdom, it was recently published by the Smith College School of Social Work.

3 Portions of this section and subsequent sections in this chapter were adapted from the article “Treatment Implications of Past Trauma in Borderline Personality Disorder” (Gunderson & Chu, 1993).

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