psychotherapist and body-psychotherapist, LCSW #6799, PCE #961
  
PO Box 241783   Los Angeles, California 90024  USA ▪ Phone: (1) 310 281 9646

What do you feel are the essential ingredients of effective trauma treatment?

Essentially, to be effective trauma therapy needs to be safe, so that the client feels safe and not at any risk of becoming re-traumatized. It’s also important to keep the traumatic hyper-arousal at a level where the client can digest the therapy; if arousal goes too high the client’s not going to be able to think and integrate their experience. That is what I call ‘putting on the brakes’.

As well, the trauma therapist needs to be flexible, trained in several different treatment modalities and theoretical bases to provide a trauma therapy can be tailored to the needs of the client. If the therapist is only trained in one model or method then clients have to adapt to that model or method. If the client can’t do that or if it doesn’t appeal, it can end up with the client feeling wrong or a failure. As much as possible the therapist should try to meet clients where they are. And it’s also important for therapists to not be so tied to their methods and techniques that they can’t place every one of them aside and sometimes just sit and talk with their clients. That’s important too, very important.

You suggest that therapists would be better off to not touch their clients, especially where trauma is an issue, but some therapists say that to not touch a client can be counter-productive. How would you deal with a client who wanted to be held?

It really depends on the client and what their resources are, and also on the therapist and what their own comfort level is. I don’t say that the therapist should never touch a client. I also don’t say that they should always touch clients. I don’t think that extremes are useful at all. But there can be a trap in having the client rely on touch within the therapeutic setting.

I would much rather teach my clients how to get their needs for touch met outside the therapeutic setting, and to have them know what kind of touch they need, what their limits are, what their tastes are, how to set boundaries and to ask for what they want, and to equip them to go out into their lives and get those needs met there. I see problems when touch gets emphasized in the therapeutic relationship. It can overly weight the transference, both positively and negatively. It can make the therapy into something more special or dangerous than it should be.

What do you think about claims that trauma can be resolved in a single session?

I think that some therapists can get real lucky. It’s not that I’ve never had a one or two or three sessions therapy, but to make that an expectation is disrespectful to the client. These days there’s an over-emphasis on method and a de-emphasis on the therapeutic relationship, and claims that trauma can be resolved in one session are an emphasis on method. There are outcome studies that show the effective resolution of trauma in three sessions, but these are done on clients who have a single standing trauma and a non-complicated background. Such studies are misleading because the vast majority of our clients have multiple traumas and/ or come from complicated backgrounds.
 
So what do you think about the current state of outcome studies in this field?

They offer good guidelines, but with limitations. For just about every outcome study showing success that is done by the proponents of some method, you can find some outcome studies done by opponents of that method which dispute it. You can almost match them one for one. My preference is to equip my clients to be able to figure out for themselves what works for them. So I teach them about self-awareness, body awareness and emotional awareness. I get them to be able to evaluate questions like ‘When we are working in this way do I feel more calm? Do I feel more present? Is my life working better? Am I more resilient?’ and so on. If the answer to those questions is primarily ‘yes’ then this is something that works well. However if they are answering ‘yes’ to: ‘Am I feeling more unstable, more decompensated, more spacey, less productive, having more difficulty concentrating and so forth? then this isn’t such a good direction. In this way clients can evaluate , together with the therapist, what works best. This is a much better strategy than imposing a method only because that method has the best outcome studies.

You treat the client as someone with resources and skills, but some approaches cast the client as disempowered, the helpless victim in need of expert assistance. How do you feel about these approaches?

They always astound me. How do they think our specie has survived until the 21st century without trauma therapy? For centuries and millennia humans have learned to resolve, and to live with and to conquer, their traumatic experiences long before the professions of psychology created the diagnosis of Post Traumatic Stress Disorder. Now okay, there’s a proportion of our population who will benefit from professional help in dealing with some of these problems, but the vast majority of humans who experience traumatic events resolve them on their own, relying on internal resources, the family, the community, the environment, spiritual beliefs, and so forth. I think it’s misleading and disrespectful to humans, to our population, to ourselves, to think anything but that.
 
In light of the events of September 11th, and the controversy surrounding Critical Incident Stress Debriefing as a strategy for survivors of trauma, what are your thoughts about the Critical Incident Stress Management movement?

I’m aware of the controversy. It’s another situation where you have a body of research that show that it’s helpful, and an equal body of research that shows either that it does not work or that it makes people worse.

When I look at it from an observer’s point of view, just with my own tools of logic and commonsense, one of the things that concerns me about it is that we do have a body of research that shows that contact is a great mediator of traumatic stress, and that’s family, church and so on. But in traditional debriefing the direction of contact is to the leader. The group faces forward and the group leader talks to individuals one at a time. This to me is illogical.

Now, I haven’t done any studies on this myself so I haven’t any evidence for my hypothesis, but I’d like to see a model of debriefing that emphasized helping people to talk to each other. And also, equipping people with the tools to go home and talk to their friends and their families about their experiences. I did some hot-line volunteer telephone counselling in the wake of September 11th, organised by a local television station. The people I talked to were overwhelmingly isolated, and didn’t know how to get in contact with others. Many were embarrassed about their feelings. They were all isolated in some way. When I talked with them my line of intervention was to get them in contact, get them out into the churches and synagogues, doing volunteer work, and get them to invite people to their homes for dinner.

Some research shows that survivors of traumatic experiences can find themselves left with positive results from their experiences, such as valuing their lives and relationships more. Can you talk to this?

This is Stress Inoculation. One of the great things that happens, and one of the pieces of evidence of the resilience of our specie, is that we can take events of adversity and find treasures in them. Certainly the aftermath of September 11th has been filled with examples of this, with the positive responses of people helping other people. I don’t have any statistics on this but I’ve lost count of the number of people I’ve heard of who’ve made major life decisions in the aftermath of September 11th because their priorities have changed. I love it when people ‘make lemonade out of lemons’.

But this idea is often by-passed in trauma therapy. We don’t usually put an emphasis on the positive. It can be great to ask, ‘Not that you would have arranged for this trauma to have happened to you, but since it did, what good can you see that could come out of it?’

You seem to stress the importance of personal resources and individual differences in your work?

Yes. This is major. After the principles of putting on the brakes and having flexible multiple systems of treatment, I think it’s the foundation of my work.

Everybody has resources. Certainly everybody who walks into my office has resources, otherwise they wouldn’t be able to get there. I want to build on the resources they already have and create new resources around those. That’s what is going to mediate the work of trauma. Trauma is a feeling of not having any resources. I remind them of what resources they have and then create additional ones so that they can feel more in control of their lives.

Individual differences absolutely have to be respected. This is one of my ‘Ten Foundations’. I never expect one intervention to work the same way on any two people. I’m always ready to be surprised because everybody’s different. You never know what can be a trigger, and you never know what can be of benefit. All of these principles are outlined in my ‘Ten Foundations of Safe Trauma Therapy’(p.98).

You’ve lectured on trauma in several countries around the world. Have you noticed whether national or cultural differences, such as perhaps emotional expressiveness, play a part in recovery?

Well, one thing we think we know (although I always say that anything we think we know is still hypothetical) is that what becomes a traumatic experience is a matter of perspective. If you have a hundred people in a room experiencing the same event, then they’re all going to experience it differently. Some of them will feel traumatized by it and some won’t, and in varying degrees. You will also find those differences across cultures as to what is traumatizing and what is life threatening, what is significant and what isn’t. So what becomes traumatizing in the first place does have cultural differences.

And then of course, add to that emotion, and then age and health, include family and friends and perhaps also the involvement of professionals, and you find that what works as treatment also differs across cultures. You have cultures where you’re not supposed to talk about your feelings in public, and you have cultures where that’s totally accepted and expected. How people regard their traumas and how they are able to resolve and reconcile them will be reflective of that.

And finally, what are your views on the training of trauma therapists?

Well, in trauma therapy I try to teach clients to be aware of what is happening in their bodies, and to identify signs of nervous system arousal, and also nervous system relaxation, so that they can know what’s beneficial to them and what’s detrimental to them. I also highly recommend that therapists develop this capacity in themselves to closely track their own bodily sensations, and their own emotional responses, so that they can know how they are responding to the therapy that they are conducting with the client. Therapists who become traumatized or triggered by what’s going on in the client and aren’t aware of that, can get into a worse emotional state than the client. The higher the sympathetic hyper-arousal goes the more chance that thinking capacity diminishes because of what happens within the limbic system with the stress hormones. If the therapist gets into the position where his system is so hyper-aroused that he is not able to think clearly anymore, he is in personal emotional jeopardy. This is also a danger point for irrational counter-transference reactions in response to the client.

Babette Rothschild, MSW, LCSW, has been a therapist since 1976, is author of The Body Remembers: The Psychophysiology of Trauma and Trauma Treatment (W. W. Norton, 2000), and is internationally recognized as a leading figure in the treatment of trauma, providing training, consultation and supervision throughout the world. She will be a Keynote presenter at the Third National Psychotherapy In Australia Conference to be held in July, 2002.