9

The Therapeutic Dance

Relational Dilemmas in Treating Complex PTSD

Many of the survivors of the battlefields of childhood abuse carry with them the scars of family wars. Having been repeatedly victimized and defeated, they remain wary—fearful of attack and prepared to retreat, mistrustful of alliances and expecting betrayal from others, and alienated from the rest of the world. Many investigators and clinicians have described these difficulties that impair the relational capacity of chronically traumatized patients (see Chapter 4). However, the experience of this interpersonal world is most vividly communicated by abuse survivors through their relationships with others, including the relationships with the clinicians that treat them. Their communications—in the form of unarticulated feelings and behaviors based on fear, anger, and despair—speak with mute torment about their past relationships and the harshness of the interpersonal world they continue to inhabit. Only by entering this interpersonal world—and by intermittently sharing the experience of the chronically abused patient—are clinicians able to understand their patients’ dilemmas and effectively treat their relational dilemmas.

ASSUMPTIONS CONCERNING BASIC TRUST

Survivors of severe interpersonal abuse experience intense internal conflict about their relationships with others. Despite having been abused, exploited, controlled, betrayed, and abandoned, many still have a persistent wish to engage with others in ways that might alleviate their pain. Yet, even these wishes are influenced by their early experiences and their own sense of disempowerment. They see other persons only through the lens of their victimization. Having little sense of their own self-worth or self-efficacy, they cannot engage in relationships that are partnerships between equals. Rather, others are seen as powerful potential rescuers who may also become powerful abusers. In this sense, relationships provide little gratification and perpetuate only uncertainty, conflict, and fear.

Underestimating the fundamental level of basic trust for survivors of childhood abuse leads to one of the most common forms of empathic failure on the part of therapists and other clinicians. Clinicians often bring their own set of assumptions about the world—usually intact assumptions about the benevolence of others and their own sense of self-empowerment and self-worth—that are often at considerable odds with patients’ assumptions about the malevolence of others and their own vulnerability. In fact, in order to maintain a normally optimistic set of assumptions, therapists frequently exercise a kind of self-preserving denial concerning the experiences of abused patients, only to be startled at times by the reactions of their patients, as in the following clinical example:

Tracy, a 16-year-old girl, had experienced a lifetime of pervasive abuse. In her infant and toddler years, she had been brutalized by her father and neglected by her impaired mother. She was subsequently removed from her home by a social service agency and was brought up in a series of foster homes and group homes that ranged from grossly abusive to distantly caring. Following placement in a residential school setting, Tracy appeared withdrawn and angry, and she had difficulties with both her schoolwork and her social interactions with peers. She was referred for therapy with a well-meaning psychiatric resident.

During an initial period of several weeks, Tracy was rather quiet. Although she responded with only silence or monosyllabic answers, she seemed willing in coming to the therapy sessions. As the resident continued to express interest in Tracy’s current and past experiences and pressed her to express her feelings, she became more withdrawn in sessions. Although she continued to show up reliably for her therapy, she appeared more and more uncomfortable. When pressed by the resident about the cause of her anxiety, she finally blurted out, “What do you want from me? Everybody wants something from me.” Panicked by her own outburst, she then tried to run out of the room. The resident quickly rose from his chair and went toward Tracey, who was blindly struggling with the door handle. She recoiled and cried out, “Please don’t hit me!”

It can be difficult for clinicians who have always trusted in the basic benevolence of the world and other people to understand the vulnerability that abused patients experience in interpersonal relationships. Although they long for a sense of interpersonal connection in the therapeutic relationship, the increased intimacy actually causes heightened anxiety rather than being reassuring. Their basic assumption—based on their early abuse experiences—is that others will exploit their vulnerability to find a way to hurt them. Even if a therapist is able to get through the interpersonal defenses of a patient and to be seen as kind or helpful, the patient is thrown into more internal conflict, trying to juggle the fragile sense of the therapist as benevolent with the certainty that the therapist will use or abandon them. This point was brought home to me when a patient in the early phase of treatment somewhat angrily told me how she felt about me: “You asked if I was able to hold onto a sense of you when I’m not here. Are you crazy? You think I like to think about you? You seem okay, but that just makes me feel more worried, wondering when you’re going to turn on me.”

This kind of conflict can be intolerable to patients and may lead to a classic type of negative therapeutic reaction. From the therapist’s perspective, the therapeutic process may seem to be going well, with patients making progress with increased interpersonal connection, more sharing of information, or more expression of feelings. But, panicked by the increased sense of intimacy and vulnerability, patients may regress or even sabotage the therapeutic process. It can be confusing and unexpected when patients retreat to dysfunctional isolation and many of the negative and sometimes self-destructive ways they previously used to deal with the world—for no apparent reason. Unless this negative therapeutic process is seen for what it is, this reenactment of early abuse-related relational dilemma can stalemate the therapy as the patient views the therapist with hostility, fear, and suspicion, and the therapist sees the patient as uncooperative, unmotivated, and difficult.

One of the most primary developmental tasks, as described by the developmental psychologist Erik Erickson (1968), is the development of basic trust. Based on experiences from the earliest years of life, children come to expect that fundamental needs for nurturing and care will be met. If such needs are not met, or are subsequently denied through pervasive victimization, children do not acquire a sense of basic self-worth, nor do they develop a sense of basic trust or interpersonal safety, beliefs that they carry into adulthood—described by Janoff-Bulman (1992) as the “fundamental schemas of their assumptive world, their core psychological structures” (p. 87). How can clinicians who have not experienced childhood abuse begin to understand the deficits in basic trust and interpersonal assumptions of their traumatized patients? I use the following imagined scenario when I teach about this subject:

In order to provide you with a new kind of learning experience, I am going to help you to understand something wonderful and dramatic about the power of the human mind. I’m proposing that we go up on the roof of this rather tall building. We will join hands and spend a minute or two concentrating on feeling that we are as light as air, and when I give the signal, we will step off the edge of the building and float lightly to the ground. Now I know that you’ll probably think this is a bad idea. But, what if I were able to demonstrate that this unimaginable feat is possible? Let’s imagine that you could see me step off the roof of the building and float to the ground, landing softly and completely unhurt. I would then turn and look up at you and say, “Now you try!” If you have any sense, you’d decline the invitation and come back down by conventional means using the stairs.

This is the kind of challenge that we offer traumatized patients when we say, “Trust me.” This seemingly innocent suggestion is perceived by patients as an invitation to participate in their own self-destruction. Many traumatized patients have observed that others around them have been able to safely participate in trusting interpersonal relationships. However, such relationships seem to present an impossible risk for them, further reinforcing their beliefs about their own incompetence and defectiveness and their sense of disenfranchisement from others.

In the early 1980s, it was often suggested that the first step in the treatment of traumatized patients involved establishing trust. For survivors of pervasive childhood abuse, this kind of recommendation now appears quite naïve, as a stable sense of basic trust is often not established until well into the later stages of recovery. Nonetheless, this difficult task must be addressed from the outset of the therapy, and it requires much time and patience on the part of both therapists and patients. For example, a patient in her fourth year of therapy once remarked, “Do you remember all the clever things that we were trying to do in the first two years that we worked together? I now realize that what I was really doing was trying my best to sit in the same room with you and to cope with the vulnerability and terror of your actually seeing me.” There are inevitable disruptions in the therapeutic relationship when patients become frightened, flee from the relationship, or try to undo the work of the therapy. Misunderstandings and miscommunication on the part of the patient or therapist, mistimings, and even errors by the therapist are an inherent part of the substance of the treatment. As the conflicts that result from these events are resolved, the patient gradually builds an interpersonal history with the therapist that becomes the foundation for a more secure attachment that enhances future growth and recovery. This process is almost never easy or predictable. Even attempts to empathize and expressions of caring can be misunderstood as threatening or intrusive by patients who have grown up in environments of pervasive victimization.

THE THERAPEUTIC STANCE

Although a psychodynamic and psychoanalytic understanding concerning early traumatic experiences is valuable in the therapy of abuse survivors, certain aspects of the classic psychoanalytic stance are not. Traditional psychoanalytic distance (i.e., the therapist as a “blank screen”) is contraindicated in work with many trauma patients. For patients with backgrounds of healthy attachments and who have benevolent interpersonal assumptions, the therapist’s quiet passivity might be interpreted as respectful or perhaps challenging. However, given traumatized patients’ backgrounds of abuse and their lack of a sense of basic trust, inactivity or withholding on the part of the therapist allows traumatic transferences to flourish. Patients often find themselves unable to articulate their concerns and feelings, resulting in silence. For patients with backgrounds of interpersonal abuse, the lack of response from therapists is commonly misinterpreted as a sign of disapproval, hostility, or even repugnance. Such traumatic transferences have their origins in a past reality and can rapidly become functionally psychotic. They frequently become the basis for interpersonal reenactments of abusive situations and can be a source of retraumatization in the present relationship.

Traditional psychoanalytic distance is designed to encourage transference distortions, which may be useful in breaking through the armor of well-defended persons in order to examine underlying feelings and attitudes. In contrast, many abuse survivors have only brittle defenses; when they break down, patients can become almost paranoid and disorganized by overwhelming thoughts and feelings. Thus, therapy with abuse survivors should generally attempt to minimize transference distortions. Therapists’ active involvement in therapy sessions is essential, and therapists must monitor periods of silence in the therapy and determine whether the silence is perceived by patients as helpful or disorganizing.

Maintaining strict neutrality with abuse survivors is at times both difficult and inappropriate. Such patients routinely have fixed and skewed negative beliefs about themselves and others, and such beliefs are likely not to change if unchallenged. For example, survivors of sexual abuse may fail to understand that the sexual involvement of adults with children is wrong. Or, even if they understand the concept, they may feel that it was permissible in their particular circumstances. Abuse survivors—even those who are bright, articulate, and educated—almost universally accept the blame and responsibility for their own abuse; their belief that they somehow caused the abuse allowed them to have a sense of control over their own helplessness and powerlessness. Therapists must be willing to be unequivocal about the idea that the exploitation of children is always wrong and that children do not cause their own abuse even in circumstances where they were provocative or took an active role. While the principle of therapeutic neutrality has merit, it must not be confused with inappropriate moral neutrality concerning such basic issues. Failure to state a clear moral position may be damaging to the therapeutic process, as it can be understood by patients as collusion with their own negative beliefs about themselves.

A stance of caring and willingness to engage on an interpersonal level is important in any effective psychotherapy, but it is particularly essential in the therapy of most abuse survivors. Whereas persons with healthy interpersonal assumptions assume that others are interested in their experience and are able to empathize with them, patients who have been interpersonally abused assume that others are disinterested and do not understand their experiences. The stereotyped response of “Um-hmm” will be quickly interpreted as inauthentic (e.g., understood as, “I can’t be bothered to try to respond”). Even saying, “I understand” can be misinterpreted. In one instance, a patient of mine erupted in an angry response: “You understand? How could you understand? You’ve had a privileged life. You haven’t been through what I’ve been through!” As a result, therapists by necessity must sometimes make extra efforts to demonstrate that they comprehend their patients’ difficulties, for example, reiterating what they have heard or how they have understood the patient dilemmas (“Do I understand you correctly that you are trying to tell me . . .?” or “I understand how difficult it is for you to tell me this”) or to acknowledge that the patient has evoked a personal emotional response (“I can feel how sad this is for you”).

Because of the tenuousness of their capacity to remain connected, patients with backgrounds of severe abuse seem to pull for therapists to be actively involved in the therapeutic relationship as participants and not just as observers. Thus, it is normative for therapists to feel much more personally involved both in the therapy and with the patients. As a result, therapists’ overidentification and overinvolvement—not too much distance—is a major hazard in the therapeutic relationship. Such therapists (particularly those who view their role as taking care of or reparenting their patients) are prone to becoming so involved in empathizing with patients’ experience that they lose their sense of therapeutic perspective. Uncritical acceptance of patients’ helplessness and their subjective sense of being overwhelmed can lead therapists and patients to a shared sense of immobilization in the treatment. Therapists in this situation also commonly feel that others do not adequately understand their patients’ pain and disabilities. They find themselves at odds with their colleagues, particularly in settings such as inpatient units (where team treatment is necessary) and defensively reject consultation. Therapists in this position may take extraordinary measures to alter the external environment for their patients, as in the following example:

I was called by a community therapist, Dr. Smith, about a possible referral of a patient to our inpatient unit. She asked a number of questions, such as whether the staff had experience working with dissociative identity disorder (DID), whether it would be possible for her patient, Karen, to be given full privileges to freely walk the grounds, whether we could guarantee that restraints would never be used during the admission, etc.—all seeming to indicate that Karen needed special care and considerations in order to be hospitalized. Even though I was unable to agree to numerous preconditions, Karen was eventually admitted to our inpatient unit after a suicide attempt. She remained extremely isolated, refusing to interact with various staff members who she claimed were controlling and demeaning to her. She demanded that all the staff address her by the names of her various personalities as they appeared from time to time. She also superficially cut herself repeatedly when she was anxious or angry.

When confronted with her dysfunctional behavior, Karen angrily referred staff to her therapist so that the therapist could tell them how to manage her: “You better talk to Dr. Smith—she knows how to work with me!” The therapist was, in fact, very confused and angry at the situation. She called the unit director and complained that the staff were too impatient with Karen and did not understand the difficulties with dissociation. She also demanded that Karen’s self-cutting behavior be accepted since it was clearly not lethal, and she had no other way to express her feelings. When the inpatient team suggested a consultation to the therapy, the therapist responded by questioning the clinical competence of the unit staff. The patient then signed out of the hospital with her therapist’s agreement.

The essential problem in this clinical illustration was the therapist’s overidentification with the patient. In her empathic understanding of her patient’s dilemmas, she overlooked the obvious fact that the patient would need to learn to live within the constraints of reality—in this case, the rules and procedures of the unit, the necessary comfort level of the staff around issues of safety, and the legitimate questioning of whether the ongoing therapy was maximally helpful.

Therapists working with abuse survivors need to maintain a dual role. While they must actively participate in the therapy and empathize with the patient’s experience, they must also maintain a sense of therapeutic perspective and direction. They must recognize that although patients feel overwhelmed and helpless, there are ways to achieve mastery over these feelings. Therapists must empathically confront patients’ demands that the external world adapt to their disabilities and ask patients to make efforts to change in order to deal with the world—a task that initially may feel impossible. Rather than becoming enmeshed in and enabling their patients’ helplessness, therapists must reiterate that patients have the choice and ability to make changes. It is helpful for the therapist to understand patients’ despair but to also express the conviction that the therapeutic process can help patients ameliorate or overcome their difficulties. For example, it is not enough for therapists to “get” why patients feel suicidal (“Given your background of betrayal and abuse and the pain you experience every day, I understand why you wish to die”); an alliance around this point alone leads only to mutual hopelessness. In addition, the therapist must also model the expectation that it is necessary for patients to move from that position (“I know it may seem impossible at times, but I think it is possible for you to play an active role in changing the course of your life so that you will not always feel so tormented”).

REENACTMENTS OF CHILDHOOD ABUSE

As outlined in the previous chapters, survivors of childhood abuse not only bring their abusive experiences to the therapeutic arena, but they also make them part of the therapeutic relationship. That is, they compel the therapist to actually assume a role in the reenactments of their traumatization. It is crucial to understand that this process is often inevitable. Given their traumatically based interpersonal assumptions, traumatized patients must see all of their adult relationships through the lens of their abuse. These powerful assumptions transform all important relationships into reenactments and recapitulations of their early experiences. However, this process is not simply a pitfall to be avoided or sidestepped; it is an intrinsic part of the treatment of these patients. The therapeutic dance, with its endless repetitions of disruptions and reengagements in the early phase of therapy, provides a model of interpersonal connection, conflict resolution, and collaboration. If recognized and skillfully managed, the interpersonal reenactment of the abuse offers an opportunity to be able to provide the experience of a relational world that is positive and growth-producing, enabling patients to learn new relational skills.

Davies and Frawley (1994) have described the four major roles that are recapitulated in the therapy of abuse survivors: abuser, victim of abuse, indifferent or neglectful bystander, and hoped-for rescuer. Patients repeatedly take on and reenact these roles, and because therapists are involved by necessity as active participants in the therapeutic relationship, they assume similar and complementary roles. These abuse-related interpersonal dynamics are extremely powerful, as are patients’ projective identifications that compel therapists to experience many confusing and overwhelming countertransferential feelings and impulses. Certain relational positions may be recurrently assumed or even become the predominant relational dynamics during phases of therapy. However, it is also my experience that these relational positions may be quite fluid, changing frequently and abruptly as they mirror and reenact the kaleidoscope of the malignant interpersonal disturbances that characterized the childhood abuse. As has been observed by several experienced clinicians and investigators (see, for example, Chu, 1992c; Dalenberg, 2004; Davies & Frawley, 1994; Pearlman & Saakvitne, 1995), therapists must both allow themselves to be engaged in these reenactments and maintain perspective and clarity concerning the process in order to facilitate a benign resolution. Again, the therapeutic dance—the cycle of abuse-related difficulties in the therapeutic relationship with repeated resolutions involving healthier relational experiences—eventually allows patients to leave behind their trauma-based assumptions and experience a more benevolent world.

In the typical crisis of a reenactment of the relational dynamics of early abuse, patients feel angry, disappointed, and/or betrayed by therapists’ responses (or lack of responses). In this situation, patients once again feel abused and may act abusively toward therapists or themselves; therapists feel cast in the role of abuser, may feel abused by their patients, and have certainly failed as the hoped-for rescuer and feel—at best—like the indifferent bystander. Davies and Frawley (1994) described a series of transference-countertransference positions that commonly occur in the therapy of abuse survivors. Transference-countertransference is a remarkably apt description, because these interpersonal dynamics are dependent on both the patient’s abusive past and the therapist’s own personal experiences.

My assumption in this discussion is that therapists should be reasonably free of any major relational pathology of their own in order to work with abused patients. Even normal personal characteristics of the therapist are heightened and distorted by the powerful interpersonal forces of the therapy (e.g., caring evolving into rescuing, facilitation becoming control, personal restraint transformed into withholding). Serious interpersonal pathology on the part of the therapist (e.g., problems with aggression, major narcissistic or social deficits) will almost certainly result in therapeutic impasses, serious boundary violations, and/or harm to both patient and therapist. One particular scenario deserves special emphasis. Not uncommonly, clinicians are drawn to the mental health professions in response to their own backgrounds of conflict or deprivation. The resulting countertransference need to rescue patients, provide caretaking, or to compensate for past abuse must be strictly examined and limited. The dynamics of the therapy must be largely driven only by patients’ past experiences, and hence become a kind of interpersonal Rorschach test that elucidates and expresses the nature of patients’ past interpersonal experiences.

As discussed by Davies and Frawley (1994), the interpersonal dynamics in the therapy of traumatized persons are varied—as varied as the individual circumstances of the abuse. Perhaps the most common interpersonal scenario occurs as the patient reenacts the position of being abused. This abused child role can take on many characteristics: helpless and devastated, angry and manipulative, appeasing or caretaking, or demanding and entitled. Each of these roles produces a complementary response in the therapist. The patient who reacts in the therapy by becoming a helpless and devastated victim often induces a rescuing response and even overidentification, but may also elicit anger or distance in response to the patient’s passivity and dependence. Patients’ hostile and angry stances frequently produce withdrawal or retaliatory rage in the therapist. Idealization or caretaking from patients may induce therapists to become passive recipients who collude with avoiding or seeing the covert agendas in a reenactment of hidden abuse. And patients’ entitled demands often produce attempts to placate or rescue, or anger at the patient’s narcissism.

The roles of the patient who defensively takes on the position of abuser are similarly varied. Patients may be overtly hostile and demeaning, covertly intrusive and invasive, distant and uninvolved, or seductive and insidiously ingratiating. Such interpersonal positions also elicit specific responses from therapists. Rageful attacks often produce attempts to appease or placate, interpersonal withdrawal, or retaliatory hostility. Covert intrusion concerning personal boundaries induces therapists to feel helplessly violated or angrily defensive. Patients who become uninvolved in their therapy—as if it is the therapist’s job to make the treatment occur—can result in therapists redoubling their efforts or angrily withdrawing. And, seductive responses can cause therapists to become troubled and passive (replicating and enacting the confusion of the abused child) or to become angry and rejecting.

All of these interpersonal positions have the potential for either providing invaluable information about the patient’s experience or resulting in impasses and failure of the therapeutic process. Resolution of these conflictual transference-countertransference positions depends on an accurate understanding of the dilemma, clarification and interpretation, reality testing, and patience. As in any effective interpersonal psychotherapy, therapists must learn to examine their own responses as a way of understanding their patients’ dilemmas. Therapists must not be afraid to acknowledge (to themselves) dysphoric feelings of anxiety, enmeshment, coldness, hostility, sadism, or even sexual arousal that can be evoked in the therapy of severely traumatized patients. Such feelings enable therapists to make clarifications and interpretations that allow patients to understand the confusing interpersonal world that their abuse continues to evoke.

Therapists must also be prepared to maintain personal and therapeutic boundaries and to set appropriate limits. Out-of-control aggression or violation of therapists’ personal boundaries are not helpful to the patient or the therapy and should not be tolerated. Therapists must ask patients to examine their relational patterns in the context of their early abusive experiences. This process is often long and difficult—to patients the dysfunctional relational dynamics are real not transferential—and therapists must use all of their patience and skill to help patients move toward mutual and collaborative relationships and healthy interpersonal perspectives. The following clinical example illustrates some of the vicissitudes involved in the shifting interpersonal reenactments of past abuse:

Joan, a 42-year-old, divorced woman, was hospitalized following a difficult series of events in which she was intrusive concerning the personal life of her therapist, Dr. White. She had initially begun to ask questions about the therapist’s personal life “in order to feel more equal—like a friend and not just a patient,” and made frequent telephone calls to the therapist’s office and home in states of crisis. Joan appeared to become increasingly preoccupied with her therapist and made personal comments in ways that made him quite uncomfortable (“You dress so nicely, but you know you really shouldn’t wear brown shoes with that suit.”). Dr. White felt unable to bring up any of these intrusions in the therapy, as he was quite aware that Joan would feel upset about her perceived sense of his rejecting her. Instead, he became quite distant in sessions, even to the extent of falling asleep on one occasion.

Joan then accused her therapist of not wanting to be involved with her, and she redoubled her efforts to find out more about him—even following him home and covertly watching him, his wife, children, and visitors to the house. When she finally confessed to this last activity, Dr. White became quite angry and threatened to terminate the therapy if such behavior ever recurred. Joan became intensely ashamed and begged him not to abandon her. Later that night, she called Dr. White and confessed to having taken an overdose of a tranquilizer that he had prescribed, and she was hospitalized. When the inpatient case manager introduced herself, Joan seemed angry and withholding. After being asked about her life and daily activities, Joan blurted out, “I know you think I’m pathetic because of my involvement with Tom—I mean, Dr. White—but I am somebody, too! You therapists all think you’re something special.” The case manager, aware of how angry Joan was becoming, controlled her wish to say something quite demeaning, and instead commented on Joan’s anger, “You seem quite upset with me as if I have insulted you. I want to make it clear that I have no preconceived notions about you, and I am just trying to understand how you have come to be involved in this very uncomfortable situation.”

After some further discussion, Joan was able to become less defensive and to discuss her distress about her relationship with Dr. White. Although she was aware that her behavior was pushing him away, she felt so exposed in the therapy and felt compelled to find out more about him both to “feel closer” and to “get something on him.” Dr. White also admitted to the case manager that he was feeling trapped in the relationship, and although he genuinely liked the patient and was committed to helping her, he felt very uncomfortable about the relationship. After some discussion, it became clear that the patient was reenacting the dynamics of the relationship with her father, who was generally demeaning and neglectful, and only becoming attentive and seductive during times leading up to his sexual abuse of her. When Dr. White broached this subject with Joan, she responded angrily, “So you’re saying that my feelings for you aren’t real and that I can’t tell the difference between you and my father! I thought you were nice—my father’s a bastard!” However, after some discussion and explanation concerning abuse-related relationships, the patient was able to calm down as she at least felt less blamed for the problems. Although she remained unconvinced about the basis of her relational difficulties, Joan and Dr. White were able to renegotiate some basic agreements concerning their relationship and the treatment. She was discharged from the hospital to continue the long process working with her therapist to try to understand and cope with her assumptions and the effects of her incestuous past.

MANAGING COUNTERTRANSFERENCE RESPONSES

Countertransference responses in the treatment of abuse survivors are quite complex and can cause considerable difficulties for therapists. One particular difficulty has been called vicarious or secondary traumatization (see, for example, McCann & Pearlman, 1990; Pearlman & Saakvitne, 1995), in which a therapist’s assumptions about the benevolence of the world are disrupted by understanding the abuses perpetrated on patients. The brutality, callousness, sadism, and even diabolical ingenuity that characterize malevolent abuse can be difficult to comprehend and accept, especially for therapists who have no previous exposure to such experiences. Therapists may have their own posttraumatic responses to hearing about the terrible details of patients’ abuse. Shock, disbelief, confusion, and even a pervasive sense of their own vulnerability can afflict therapists, who then struggle to regain their own sense of safety and stability. Such reactions are common, and clinicians must use their own personal interpersonal supports—friends, colleagues, consultants, or their own therapists—to help regain their equilibrium. Fortunately, most clinicians are generally able to adjust to even new and horrifying knowledge, to integrate such information, and even to reinstate some healthy denial and dissociation in rebuilding a new and workable set of assumptions about the world.

Overidentification and overprotection of patients are common countertransference difficulties. In addition, fascination is a particular difficulty, especially with the rather dramatic symptomatology of the multiple identities of patients with DID (Chu, 1994; Kluft, 1989a). However, the most difficult countertransference problem in working with abuse survivors may be unacknowledged therapist discomfort. The level of involvement that is necessary to work with traumatized patients and the inevitable recapitulation of abusive interpersonal relationships places significant emotional strains on therapists. In addition, the extraordinary psychological pain experienced by patients frequently causes them to be narcissistically preoccupied and unable to have a sense of the experience of others around them, including the impact of the therapy on their therapists. In relationships with patients, therapists often feel that their work and efforts are often disregarded or invalidated, and, given the slow pace of many treatments, actual gratitude on the part of patients for sometimes lengthy and extraordinary services may be long delayed.

Many patients go through episodic crises, endanger their own lives, wrestle with their intolerable conflicts and unbearable experiences, and have numerous regressions where they are unable to take responsibility for themselves or control their experiences. As a result, therapists are often placed in positions where they feel anxious, confused, and burdened. However, therapists are frequently unable to acknowledge the extent of their own discomfort or even anger with both the therapeutic process and with patients. Instead, it is usually much more ego-syntonic to acknowledge only compassion for the patients’ pain and sympathy for their struggle to overcome their past abuse. Moreover, many patients give both direct and indirect messages for therapists not to become upset, frustrated, or angry. Patients perceive the all-important and sustaining interpersonal bond between them and their therapists as very fragile, and they fear they could not withstand any expression of therapists’ discomfort or anger. In addition, many patients have had previous experiences with anger as out-of-control and destructive, and they see any expression of anger as inevitably leading to abuse. Many patients who are unable to integrate their own conflictual feelings are unable to see their therapists as being complex and multifaceted. Thus, any indication of frustration or anger is seen as being the therapist’s primary affect toward them. Therapists’ unintentional collusion with patients by not acknowledging their dysphoric feelings (even to themselves) is remarkably common.

Unacknowledged anger can inhibit appropriate therapeutic responses. For example, therapists can fail to set appropriate limits or define boundaries because they unconsciously fear that they are acting out their anger or sadism. Even in situations where therapists can acknowledge to themselves that they are angry, they may confuse primary and secondary motivations. Limit-setting in order to preserve the treatment frame is the primary motivation. Any gratification of anger or sadism that therapists may feel by confronting patients is secondary. When consulting on cases in these kinds of situations, I usually counsel therapists to be candid in acknowledging their own feelings and then to be clear to themselves that the interventions are for the primary purpose of restoring a healthy therapeutic relationship, and that if they are secretly gratified by the process they should just accept it.

Therapists’ experiences of unacknowledged discomfort, frustration, and anger vary considerably, and therapists are not immune from utilizing common so-called primitive defense mechanisms. For example, although few therapists are overtly hostile, many find themselves becoming neglectful or distant. This kind of acting out is usually manifested in failure to follow through with commitments, forgetfulness concerning appointments, habitual tardiness, feeling detached or drowsy in sessions, or behaviors such as interrupting sessions to take telephone calls, excessive note taking, or scheduling appointments in an erratic or unpredictable manner.

A more common manifestation of countertransference discomfort occurs through therapists’ use of reaction formation. Instead of acknowledging frustration or angry feelings about patients, therapists instead become extremely worried and concerned about patients and convinced that they need to redouble their efforts. This kind of response can be detrimental to the therapy, as therapists avoid bringing up any issues that might disturb patients and exercise a level of overprotectiveness that does not allow patients to develop psychologically. This overprotective stance is also very painful for therapists, who tend to feel anxious, enmeshed, and burdened, as in the following example:

Dr. S., an experienced and respected therapist, consulted me for difficulties he was encountering in his work with a survivor of extreme familial neglect and physical abuse. For several years, he weathered many difficult periods, most of which were marked by the patient becoming extremely controlling concerning the nature of the therapy and the therapist’s responses; in such situations there was always the implied threat of the patient killing herself. He gave me one example where the patient called him for help on her cell phone while standing on the roof of her house, threatening to jump to her death. Dr. S. found himself becoming so anxious about the patient that he worried constantly and even woke up at night with anxiety about her. He had frequent emergency appointments with the patient and called her several additional times per week to make sure she was safe.

In the consultation meeting, he was highly anxious and tearful as he began to describe his fears about the patient’s safety and his uncertainties about the therapy. I suggested to him that he felt burdened by the work and might be angry about it. At this point, he denied being angry. I reminded him that he had been dedicated to helping this patient for years, making sometime heroic efforts on her behalf, and that she had responded by repeatedly threatening suicide in a way that evolved into his feeling responsible for her safety—an untenable position. After being able to discuss his concerns and to acknowledge his frustration about being manipulated, Dr. S. was able to gently confront the patient on an ongoing manner about the nature of the therapy and to set some reasonable limits. After a period of some turmoil, the therapy became much more stable and contained. Dr. S.’s overall level of anxiety and sleep returned to normal.

The most painful form of countertransference reactions occur when therapists are unable to acknowledge their countertransference anger and actually project their own anger and sadism onto their patients. In the therapists’ eyes, the patients then become a seemingly real and substantial threat. Not infrequently in such situations, the therapists may actually develop a mild form of posttraumatic stress disorder, complete with unwanted intrusive thoughts, nightmares and disturbed sleep, avoidant responses, and even startle responses. The therapists actually begin to feel threatened by the patients and to dread sessions or other interactions. Furthermore, the therapists feel as though they cannot abandon (escape from) the patients, but they feel impotent to make any kind of positive change in the therapy. The following personal vignette illustrates such a dilemma:

Several years following my graduating from my residency, I undertook the treatment of a young man for what I understood to be the aftereffects of emotional and physical abuse and neglect. By that time, I had already had experience with treating complex trauma patients, and I should have been able to avoid the ensuing enmeshment. In retrospect, I was quite overdentified with him; he was about my age, was interested in the mental health field, and was a gifted artist. Over the course of several years, the usual boundaries of the therapeutic frame became eroded. In response to what seemed like legitimate needs at the time, we had meetings outside the office and formed a kind of dual relationship as both therapist-patient and quasi-friends. This made it more difficult to maintain any real sense of a treatment frame, and I responded to crisis by providing frequent sessions and taking numerous emergency telephone calls. At one point in time, the phone calls became much more frequent and changed in tone to become more entitled, angry, and demanding. I began dreading the calls and even started to jump at the sound of the telephone ring in my office—a true startle response. I began to doubt my ability to help the patient and to wonder if I could endure continuing the treatment; I fantasized that the patient would magically disappear and I would be relieved of my burden.

At the point that my physical and mental health were beginning to be affected (since I had PTSD-like recurrent intrusive thoughts and disturbed sleep), I finally had some insight into the process. I realized that I had allowed the situation to become unmanageable and that I was projecting all of my anger and frustration onto the patient as if he could destroy me. I realized that it was perfectly possible for me to restore some sanity to the therapy process and that I was more than capable of providing competent treatment. Over the next several weeks, I was able to introduce some boundaries back into the therapy and to establish the necessary distance to restore some reasonable therapeutic perspective. Some time after that, it became clear that the patient’s crisis situation, the intrusions into my life, and his entitlement and irritability were caused by an emerging manic episode that I had failed to recognize because of the level of my overinvolvement.

This kind of reaction by therapists, although extreme, is understandable in the context of the patient’s dilemmas. It is yet another recapitulation of the patient’s unresolved early abuse. In the setting of the therapeutic relationship, the patient becomes the real or imagined abuser. In response to patients’ cues, therapists find themselves in enmeshed relationships in which they are highly emotionally invested and from which they feel they cannot exit. They feel dysphoric, panicky, despairing, and limited in their options and choices. In short, they have assumed the position of the abused child in a reenactment of the abuse. It is essential for therapists in this position to directly address these issues. This type of reenactment must be understood and interpreted, and patients and therapists must move back into mutually respectful, collaborative relationships.

Professional supports through ongoing consultation, attending continuing education programs, and talking with supportive colleagues are an essential part of working with patients with complex posttraumatic and dissociative disorders. Given the intensity of the patient-therapist relationship, the powerful affects related to traumatization, and the slow pace of treatment, there is often little or very intermittent gratification for therapists. Clinicians must use their professional and personal support networks to help them maintain their own equilibrium and to hone their professional skills. Especially in situations of transference-countertransference enmeshment, therapists must practice what they preach: reaching out to others for interpersonal connection and support is an essential part of human experience and is particularly necessary in times of difficulty or stress. After all, traumatized patients are often very astute in observing their therapists, and patients’ dilemmas cannot be resolved until therapists are able to understand and to model how they are able to resolve relational impasses.