    
A TRAUMA CASE HISTORY
©1995 Babette Rothschild, MSW, LCSW Member:
National Association of Social Workers; Member:
International and European Societies for Traumatic
Stress Studies
Part one of this article is published in Somatics,
Fall 1996, part two is slated for Spring 1997.
*If you would like a reprint for duplication and/or
other articles, let me know. You are welcome to
distribute it to others so long as my copyright and
signature remain included.*
There is a growing body of literature on
Post-traumatic Stress Disorder (PTSD) that suggests
that PTSD has physiological elements - that is,
heightened activation of the autonomic nervous
system (ANS) - as well as psychological elements.
Articles and books about the physiology and
psychobiology of stress and PTSD abound (see, among
many others: Figley 1985, Loewenstein 1993,
Puglisi-Allegra & Oliverio (Eds.) 1990, Scrignar
1988, van der Kolk 1993). PTSD may be the condition
that finally convinces both the medical and
psychological communities that there is a connection
between the mind and the body.
The following case history is particularly
illustrative of this connection and demonstrates a
sampling of techniques that address, support and
heal this connection as a part of an integrated
therapy for the treatment of trauma.
NOTE 1: This is a single case that illustrates
certain general principles and techniques. It is in
no way meant to comprise a complete instruction or
theory in somatic trauma therapy. Each individual
and his/her trauma history are different and must be
treated on an individual basis.
NOTE 2: R's identity has been protected. She has
given permission to write about her case. She has
also reviewed and approved this manuscript for
publication.
Case Introduction
R is a Western-European woman in her mid-thirties
who at 19 was raped during a student vacation in a
middle eastern country. She works as a social worker
for immigrants and often comes in contact with
refugees from the Middle East. She sought therapy
after noticing that over the previous few months she
had growing anxiety at work which was beginning to
interfere with her ability to continue her job. She
was having increasing flashbacks of the earlier
rape, difficulty concentrating, and periodic
nightmares.
The symptoms cited above indicate posttraumatic
stress, but technically, R's is not a case of
Posttraumatic Stress Disorder (PTSD) (APA, 1994) as
she does not meet the criteria; she is too
functional in her daily life. I evaluate R to be
otherwise relatively stable and well functioning.
I have chosen to write about R's case for several
reasons. First it is a good example of a limited (11
session) somatic trauma therapy with a
single-standing, non-complex trauma (Herman, 1992).
Second, I found the cultural aspects both
interesting and challenging. And, third, therapy
with R demonstrates both the psychotherapy and body
therapy aspects of somatic trauma therapy and is,
therefore a good example of the mind/body
integration work possible with body-psychotherapy.
Intake Interview
I began with R by taking a careful case history. As
we discussed her past and current situation, it
became clear that her current anxiety had been set
off after she had been threatened by one of her
Middle Eastern clients several months earlier. She
hadn't thought much about it at the time, but could
now see the connection. She had no other incidence
of sexual assault in her history.
I always take a complete case history to provide a
three-dimensional picture of a trauma client. This
helps to assure that I will treat the client as a
person with a history and personality of which the
trauma is just one aspect. Sometimes there are
non-traumatic family dynamics, patterns or
personality traits that could make the client more
vulnerable to trauma. It is also possible that there
could have been other traumas that were or became
connected to the presenting trauma.
I established the frame of the therapy which
includes my fee, cancellation policy, and an
agreement that R will work with this trauma until
finished, (not quit in the middle). R discussed some
financial problems, but as she had gotten financial
support from her employer, felt she could agree to
this.
It is a good idea for the trauma client to agree to
complete the therapy. Trauma therapy is very
difficult - who wants to remember a trauma? - and
such a contract provides some degree of protection.
It is not a good idea to begin a somatic trauma
therapy, triggering the bodily responses and
emotions involved, unless there is good chance the
client will see it through.
Somatic trauma therapy is most productive in
two-hour sessions where there is ample time for the
client to confront issues, integrate material and
recover. Some clients prefer to come weekly, some
biweekly to have more time to process the material
raised in the therapy.
We also briefly discussed R's situation at work
and she agreed that for the time being, she wouldn't
take potentially violent clients - she was already
receiving support for this from her colleagues.
Therapy Session #1
R outlined the story of the rape.
I kept R from going into detail at this time, as I
could see signs of sympathetic nervous system
activation (dilated pupils, pallor in face,
increased respiration), and wanted to keep that at a
minimum. At this point I only wanted to be oriented
on what we were to work with, and didn't want her
experiencing the trauma. (With a more frightened or
less stable client, I might have waited many
sessions before asking for information about a
trauma, focusing instead on establishing the
client's sense of safety both in and out of therapy.
R is not anxious about the therapeutic process,
itself.) I expected to be told only a partial story.
Dissociation in varying degrees is typical in
trauma. The relationship between trauma and
dissociation is well established (Loewenstein, 1993;
Herman,1992; Braun, 1988). Traumatic events, if
remembered at all, are often remembered only
partially. Missing events, details, physical
sensations, etc. are common.
R had been traveling with a group of friends, but
had chosen to go off by herself one day with a
polite young Arab, M, who offered to show her the
city. No one thought much about it. M was very
knowledgeable and showed her much of the city she
wouldn't have otherwise seen. Towards the end of the
day they encountered one of M's friends, and went
back to M's apartment. As night fell, she was told
by M that he would have sex with her, but would not
allow his friend to because M was "in love" with
her. She protested and asked to be taken back to her
hotel, but was told that if she didn't allow it,
they would both have sex with her. R reported she
then went dead in her body. The next morning M
showed her back to her hotel, stopping to buy her
breakfast on the way. When they arrived, her friends
expressed concern for where she had been. R was so
embarrassed and ashamed about what had happened she
didn't say a word about the rape; she told her
friends she had spent the night dancing.
I decided that the BODYnamic running technique would
be useful in R's therapy. I suspected that her
"going dead" was in response to feeling trapped
(suppression of flight reflex (Levine 1992; Bloch
1985)). I also judged that she was stable enough to
be able to benefit from the running technique as an
aide both to reduce her anxiety and to loosen some
of the freezing/deadness in her body.
I would like to caution that the BODYnamic running
technique, while extremely useful and powerful, is
contra-indicated in many instances of somatic trauma
therapy. It is not appropriate for use with clients
who have psychosis, dissociative disorders or
borderline personality disorder; where the traumatic
experience included fever, drugs or unconsciousness
- head injury, anesthesia, fainting, etc.; with
actual/current traumas, especially where there is a
history of trauma; and any time the client becomes
more rather than less anxious from its use. It can
be used in cases of Complex Posttraumatic Stress
Disorder if not complicated by any of the
aforementioned limitations. However it should not be
used before the client has achieved relative
stability in his/her life, is able to contain
powerful emotional release, and is able to
differentiate the traumatic event as something that
occurred in his/her past. For in depth discussion of
the BODYnamic "running technique" see:Jørgensen,
1992.
The client "runs" lying down with feet pummeling
into a mattress with arms swinging and head pointed
forwards as s/he imagines running along a route to a
"safe place". It is important that the movements be
running movements and not allowed to become a
kicking/hitting "temper tantrum" - one of the
reasons for keeping the head pointed straight and
not rolling from side to side.
The client chooses the safe place (Jørgensen 1992).
It must be a real place with a real person(s) the
client has or had a close relationship to. One
reason a trauma sufferer remains affected, is
because s/he lacked appropriate support and contact
at the time of the trauma. Running to the safe place
accomplishes several goals: 1) it helps to
physically loosen traumatic freezing, 2) it helps
re-establish the reflex of flight, 3) it creates an
imprint of contact rather than isolation as a result
of the trauma.
We then used a good amount of time to establish
her "safe place" to run to. She chose to run to her
home at the time of the rape, and chose 4 of her
current friends to be there. We went over the route
to the safe place, springing from the Mid-Eastern
country to a landmark close to the house and
continuing along a route that would eventually lead
her into the house and to her friends who would be
waiting for her. She drew a map and named the other
landmarks along the way so I could help guide her as
she "ran". She decided how she wanted to be greeted:
for the friends to ask "What happened?!", but not to
touch or hug her unless she reached out for contact.
She then practiced running to the safe place. Before
we ended this first session, we discussed if there
were any of her current friends she might like to
invite to future therapies, as in-person supports -
"helpers". R choose one of her colleague/friends, a
young Middle-Eastern woman whom R felt very close
to.
It is often a good idea to have a client invite one
or more "helpers" to shock therapy (Jørgensen 1992).
It is important that the helper be instructed not to
do anything unless told to, including giving comfort
to the client. S/he is there as a witness and
support. It is important to decrease the isolation
of trauma as much as possible. Of course, the use of
helpers will also decrease transference to the
therapist - which can be an advantage in a limited
trauma therapy, but contra-indicated when trauma
therapy is a part of a longer, dynamic or
characterological psychotherapy, or
body-psychotherapy. In R's case use of a helper was
serendipitous, which will be illuminated as the
therapy progresses.
Therapy Session #2
I suggested that R begin the therapeutic work with
events that occurred after the actual rape. An
important source - perhaps the most important - of
lost resources lie after the traumatic event, as
resulting PTS or PTSD usually indicates that a
person was not met, supported, helped as they needed
to be during the trauma and after it. This case
study illustrates this principle well: how grasping
the resources lost (hidden) after the traumatic
event, in this case, rape, made approaching the rape
situation itself, much less difficult and anxiety
provoking. There are also important resources in the
events before a trauma. Often a ping-pong approach
is best: slowly nearing the core of a traumatic
event from events both after and before, going back
and forth.
I listened to R's words and observed reactions of
her body. I was especially interested in noticing
somatic signs of autonomic nervous system (ANS)
activation - both sympathetic (SNS) and
parasympathetic (PSNS) - (changes in skin color or
temperature, sweat, pupil size, breathing patterns,
muscular tension, pulse rate, etc.). I didn't just
rely on my observations, but also periodically asked
R what she was aware of in her body. This was both a
feedback for me, and an encouragement for R to sense
her body and it's changes. It was helpful for R to
connect with her body as she might have fully or
partially dissociated from it because of her trauma.
Body awareness is also one of the most valuable
tools of somatic trauma therapy (Rothschild and
Jarlnæs, 1994; Rothschild, 1993). It is the changes
that occur in the body that indicate both what is
happening within the client and what needs to
happen. For example, when R becomes stiff in her
legs (PSNS activation), or shows signs of anxiety
(cold sweat, wide pupils, increased heart rate - SNS
activation), this is the time to run to the safe
place. It isn't usually a good idea to have the
client run when dissociated (i.e., spaced out, areas
of physical numbness, feeling of depersonalization,
etc.). If dissociation increases, that must become
the focus of the therapy - what happened that the
client dissociated? - with association accomplished
before continuing use of the running technique.
Additionally, you shouldn't use the running
technique with clients who have dissociative
disorders (depersonalization, multiple personality,
etc.), as this technique could increase the
dissociation.
R talked about what happened after she returned
to her home country. She had still not told anyone
that she had been raped, but a vaginal infection
forced her to seek medical treatment. A gynecologist
was the first person she told about the rape. His
response was cold and clinical, with an edge of
sexual interest that increased her feeling of shame.
When reviewing a trauma there is a choice of using
past or present tense, dependent on the stability of
the client and the type of techniques used. Use of
present tense will bring the client closer to the
trauma, traumatic reactions, and activation of the
ANS. Often when using the running technique, it is
useful to have the client talk of the trauma in the
present tense as she gets in touch with it, and then
change to past tense when she reaches the safe
place. This can help attend to both the inner sense
that the trauma is occurring now, and the external
reality that the trauma is over and survived. The
goal of therapy is, of course, to clearly separate
past and present and relegate the trauma to the
past.
As her legs began to stiffen, or she began to
become anxious (both ANS signs of trauma), I had her
run from the scene, to her safe place. In the safe
place she told her helper what happened, then, and
how that has affected her till now. She expressed
anger at the doctor's insensitivity, and she related
difficulties with her current doctor and made a
decision to switch to another one, before having her
next examination. She felt the impact of not having
told any friends, how alone she was at that time,
and how ashamed. She cried deeply.
It is crucial to prevent re-traumatizing of the
client. Therefore, as soon as the client begins to
show even small signs of ANS activation (stiffness,
anxiety, pallor, cold sweat, etc.) that s/he run to
the safe place. This will often (but not always)
trigger an outpouring of blocked emotion. The client
gets contact from both therapist and helper(s) and
tells about the past events that led up to the
reaction. Memory expands and events and emotions can
be associated. This is a critical opportunity for
the client to assign the trauma into it's rightful
place in time, the past, separating past from
present. The trauma sufferer hasn't fully realized
that the trauma is past, and, therefore, survived.
The associated memory and emotional impact of the
insensitive doctor who examined her following the
rape helped R to claim more control in her life by
deciding to replace her currently inadequate doctor.
This is one of the best results of trauma therapy:
when the client is able to use the therapy to
positively impact on his/her current life.
At this point she remembered eventually telling
one of the friends she had traveled with, both with
relief and shame and fear of being judged. I asked
her to make eye contact with her helper and see how
the helper would receive her - testing the reality
of her feeling that everyone would judge her.
The helper, was very touched by R's feelings, and
their contact was intense. R reached out and took
hold of the helper's hand several times throughout
the session.
At one time R looked at the helper and realized
that the helper's nose resembled the nose of the
rapist. They laughed about this and R said she
didn't feel this was a problem. The next time R ran
and arrived at her safe place, the helper covered
her nose with her hand - half in seriousness and
half as a joke. R first laughed, almost
hysterically, then the laugh deepened into sobbing -
the impact of the rape associating closer. I later
talked with the helper about not making further
spontaneous gestures, that she was just to be there
and not do anything unless asked.
This illustrates both advantages and disadvantages
of using a helper. This helper inadvertently
triggered a deepening of the therapy process. But
she also acted without instruction from the
therapist. Helpers who cannot follow the therapist's
instructions, can not be allowed.
Before we ended this session, R commented that
the noise from the street outside my office window
reminded her of the busy streets of the city in
which she was raped. I suspected she was confusing
past and present, so I had her run again to her safe
place. This time she ran full-out, with the flight
reflex fully engaged, and sobbed when she arrived at
her safe place, releasing a large portion of her
anxiety.
It is not a good idea to let a client leave a
session in the trauma. Sometimes a session must be
extended to prevent this. The therapist must listen
to the client's words and look for signs of ANS
activation.
R was tired and felt a little "stoned" when we
ended and I intervened to insist she take the train
home, instead of driving (an hours trip). Her helper
agreed to assist R in securing her car (she could
fetch it the next day on her way to work) and
accompany her to the train station.
It is often necessary for the therapist to present
safety limits for the client. At this point it would
not have been safe for this client to drive such a
long distance home.
At the end of this session I had R and her helper
"de-role" to keep their out-of-therapy relationship
clean of transference and rescue (Jørgensen, 1992).
It's a good idea to do this after each session with
client and helper(s). It's a simple ritual. The
client says, "you are no longer my helper, you are
(helper's name), my friend (colleague, etc.)." The
helper responds, "I am no longer your helper, I am
(name), your friend (colleague, etc.)."
Therapy Session #3
R reported that after the helper had departed the
train station, she found a man in the women's
toilet. R became instantly angry and demanded he
leave. Luckily he was only a passive drunk who had
chosen the wrong door, but she was quite shaky
after. We discussed issues of getting help vs. doing
things herself. She made a contract that until we
were finished working on her shock, if anything like
that occurred again, she would seek help, and not
handle the situation herself. I explained that while
working on shock, one isn't always able to evaluate
what is and isn't safe in the area of the shock one
is working with. She agreed to do this. We also
discussed the coincidental nature of what had
occurred, and joked some about how it seems the
universe arranges for us to be challenged as we work
through our issues. (It happens a lot!!) She then
remembered - with both fright and fascination - that
as a child she had met a flasher on a train.
It may be necessary to make protective contracts
with clients during trauma therapy. It is not
uncommon to make a safe driving contract with a
client working with a car accident, for example, or
a contract for extra caution at night with a client
who has been assaulted. This action supports
possibly reduced orientation resources. This is
another instance of the therapist intervening to
provide safety for the client. It might have been
better if I had first explored with her what she'd
like to do in a similar situation, but the contract
is a good idea. It is a common occurrence that a
trauma client is confronted with situations that
mirror the issues being worked with and that
illuminate some of the themes involved. The popular
term for this phenomenon is "synchronisity". Here
the theme of handling a, possibly, dangerous
situation on her own and not seeking help was
demonstrated.
It is important for the client to feel in charge of
the therapy process, and at the same time the
therapist must provide his/her expertise. Steering
of the therapy process is more common with a somatic
trauma therapy then in a dynamic or characterlogical
therapy. But no step is taken without the full
understanding and consent of the client. Trauma
occurs because of a loss of control (of the car, at
the hands of the assailant, under anesthesia, etc.).
Having a large degree of control over the therapy
process - i.e., trusting that all "no"'s and
"Stop!"'s, as well as the client's own ideas for
direction will be respected, etc. - will increase
his/her sense of safety in the therapy and in
his/her life.
I suggested that today's therapy should focus on
the events before the rape. How did she choose that
trip, with those people, to that country? How was
the travel, what were problems and enjoyments along
the way?
They traveled through Europe and then into the
Mid-East. The contrast of cultures was intense. Over
and over as we discussed how it was to be in the
country where she was raped, she remarked that she
hadn't remembered how tense, and often uncomfortable
the atmosphere had been for her - she had only
remembered the excitement. It became a true asset
that her helper was also from the Mid-East, as we
were able to utilize her expertise in establishing a
true sense of the difference of energy, norms and
values compared to Western European countries, and
how that also effected attitudes about women,
especially western women, something that may have
contributed to the rape.
There can be much forgotten in the time before a
trauma. It is important to associate these memories
and extract the resources - often clues to
orientation - contained in them. Sometimes a sense
of curiosity, self-confidence, joy, etc., can also
be lost when it seems that such traits or feelings
resulted in a trauma. This must also be reclaimed.
Decisions like, "I'll never ________." are often
based in events before a trauma.
Again we worked with the memories, and she ran
when signs of ANS activation appeared, using the
safe place for processing of information and
feelings - relegating the rape into the past. At the
end of this session R was surprised to realize how
much she had repressed/dissociated her emotional
memories of that trip. She realized that, on the
whole, she had sugar-coated her memories. She had
not enjoyed her visit to the Mid-East!
PART II
Therapy Session #4
R reported encountering a strange man on the
train. He seemed to nap with his head on her
shoulder while brushing her leg with his (seemingly
asleep) hand. When she realized he wasn't asleep,
she became frightened and appalled, but was afraid
to move, lest she offend him. She was not able to
keep her contract of getting help. We discussed
options: choosing populated cars to sit on, and
moving if she is uncomfortable, etc. She thought it
might be good to say, out loud: "What do you think
you are you doing?" or "Stop that!" - such protests
will both stop an offender, and draw attention to
the situation - and I had her practice this a couple
of times.
Again, she encountered synchronistic situations.
Some of her paralysis (inability to move) was
directly related to the rape and I suspected she
would be able to move in a similar situation when
she had finished her therapy. How much of these
encounters were a magnet of her personal process,
and how much of her heightened awareness - have
these kinds of things been happening before without
her noticing? - was not clear. At any rate it was
important to discuss her options for response and
train her in them.
We decided, in this session, to take a look at
the situation immediately following the actual rape.
Here the connections to her inability to act against
an offender or seek help gradually became clear. I
gave continued attention to R's body awareness and
signs of ANS activation.
When R and M left his apartment after he raped her,
R felt she had to be nice to him. She didn't know
where she was or how to get to her hotel. She didn't
speak the language. She felt dependent on M to get
her back to safety - dependent on the man who had
raped her! So she let him hold her right hand. As
she remembered she could feel the tension in the
hand and the impulse to draw it away.
As R approached her friends with M, she had an urge
to scream out, "Call the police, he raped me!", but
stifled it, by tensing in her throat; she feared the
reaction of the crowd.
Here the helper's culture was, again, an asset as we
discussed if R should or shouldn't have yelled out -
what kind of reaction was R likely to have gotten if
she had?
The helper was sure that a Mid-Eastern crowd
would have considered R, a young European woman
accusing a Mid-Eastern man of rape, to be a whore
and would have, at best, ignored her, at worst
accused her or hit her. The police, the helper was
sure, would not have taken the situation seriously,
and may have arrested her, instead.
This cultural insight is important in alleviating
R's guilt about not seeking help or retribution. If
R had not had this helper, it would have been
appropriate for us to do some research with regard
to cultural norms. Here, supporting her intuitive
defenses is of utmost importance. In trauma, people
call on unconscious defenses and make unconscious
decisions based on the knowledge they have at the
time. These trauma decisions and trauma defenses
have, also, a trauma logic (Rothschild and Jarlnæs,
1994). They are always appropriate to the situation
when judged from that angle, but can carry much
guilt and be harshly judged when viewed from a
non-traumatic perspective.
I had R return to her memories. I had her sense
what she had to do in her body to make herself hold
the rapist's hand and not cry out: tense her arm
while relaxing her hand, tense her throat, not run,
etc. At the same time I encouraged her to consider
how smart she had been - how she had likely saved
herself further harm, shame and anguish.
Trauma decisions are two sided. They are made in the
service of survival, and sometimes require
compromise of normal instincts and feelings.
But when she ran to the safe place, I urged her
to yell out, "I've been raped!!" - it is now safe to
dissolve this defense! -, timing my intervention as
her anxiety rose, but before it became so high she
again froze. With her shout came a strong outpouring
of emotion: fear, shame, rage. She swore at the
rapist, and began hitting with her right fist,
finally taking back her hand. For the first time she
became angry at the rapist (she'd always been angry
only at herself) and how he had set her up. Now she
was ready to begin to separate her guilt and place
blame with him. For the first time she realized that
it was he who was in the wrong. (She knew - and we
still needed to work on - that there was something
amiss in her judgment that she walked into the
situation, but she realized at this point that the
responsibility for the rape, itself, clearly was
M's.) R had clearly said "No!" to his sexual
advances, and she then remembered that M had
attempted to strangle her when she resisted.
This is an important step. It is crucial to assign
guilt. A trauma survivor is all too ready to take
all blame, and many therapists are too quick to
place all blame on the offender. For the client to
reclaim all his/her power and sanity, the truth of
guilt must be illuminated. A rapist is responsible
for a rape. Period. And, s/he who is raped must be
willing to look at how s/he came into the situation
- SO THAT S/HE CAN PREVENT THE SAME FROM HAPPENING
IN THE FUTURE. Orientation is a first response to
threat: where is the danger? what is it? how do I
react? When one has been traumatized, often it is
because there was something missing in this stage.
And orientation for future safety is always reduced
in trauma - often resulting in a traumatized
individual being more vulnerable to future trauma.
It is important that this resource be restored. In
all animals, orientation is a reflex that involves
stopping and locating the source of threat.
Physically this requires sharpness of eyes and ears
and mobility in the neck (Levine 1992). In humans,
orientation additionally requires being able to
process information and intuitive signals.
R wanted to further express her rage through
hitting a pillow. As a part of setting up a safe
situation for this, I required that she stay in
contact in the here and now and cautioned that she
shouldn't expect to "get rid of" all of her rage. I
suggested that she needed to keep some of it and
contain it, as a part of her power, and to help her
to react more protectively on the street, in trains,
etc.
It seems a common misconception of
Body-psychotherapy, that one can or should "get rid
of" feelings. I have heard many therapists state
this, and it is often a goal of clients. I don't
believe this is possible, nor, necessarily
desirable. One can become better at expressing or
releasing feelings, but humans continue to have
emotions. Containment of emotion is an equally
desirable goal of therapy. One needs both the
ability to release and the ability to contain
emotions. Ideally the individual should be able to
choose expression and containment in differing
situations. Containment of emotion requires a
certain amount of body tension, which is desirable
as an additional aid to personal defense.
R expressed her anger and cried that it was not
fair that M got off free and she had suffered all
these years. I suggested that she allow herself a
fantasy of what she would have liked to happen. She
is very quick and clear: he should have been caught,
tried, and castrated. "Men who can't contain their
sexual hormones, shouldn't be allowed to have them."
She was sure she didn't want him killed, and didn't
want him to suffer pain, just be deprived of the
hormones that were a cause to what he did to her.
It is important to allow the client to fantasize
desired outcomes - and for the therapist to help the
client to keep the fantasy as fantasy especially
when there are desires for revenge. Fantasy helps
the victim to feel his/her power and relegate
responsibility.
I told R that in the US, they call this "date
rape" which is a classification of rape not as
recognized in Europe at this time. I explained that
date rape is rape that happens between known
parties. Usually the encounter is friendly, even
flirting, but becomes rape when the man presses his
sexual desires over the woman's protests. In parts
of the US it is considered as serious as rape by a
stranger.
R left this session feeling different. For the
first time, she didn't feel guilty that she was
raped. Instead she felt angry at the rapist who did
it.
This was a pivotal therapy. The issue of guilt in
place, the rest of R's therapy will be much easier.
Now when she works with the rape itself, R will not
be as plagued with doubts about who is in the wrong.
And when she approaches looking at how she got
herself in that situation, the guilt of the rape
itself, will be separate from her guilt for not
having been more cautious.
Therapy Session #5
Since the last session R had been ill twice, once
with a stomach flu and today with a cold. It was
unusual for her to be ill. I discussed with her some
of the physiology of stress and its effect on the
immune system.
It is likely that R's illnesses are related to her
therapy. Since stress affects the immune system, it
is not unusual for a client to become ill during
trauma therapy (Bloch, 1985).
She's also been more irritable at home, and more
assertive with her husband and family.
We agreed to focus R's session on the events leading
up to the rape. R carefully described how she met M.
Several times I stopped her and had her go back and
relate further details. I was wanting both to
increase her association and to engage her
orientation - were there danger signals she may have
sensed, but ignored?
Since dissociation is a main feature of trauma, it
is good to have the client repeat, especially when
the therapist senses s/he is glossing over details.
Memory of details is a part of increasing
association. Remembered details may also hold clues
to orientation or trauma decisions. I am also, of
course, continuing to monitor activation in the ANS
and help R to increase her body awareness.
R began by telling how she met M in a cafe while
having coffee with a friend. M came to their table
and started talking. R then skipped to another
memory: the day before an older Arab man had
approached R and her friends, offering to buy R. She
says that this was only a joke, and she went along
laughing. But as she discussed it with me, she began
to feel irritated, remembering a male friend
bartering with the Arab. She displaced this
irritation towards me: why am I focusing on this
unimportant joke? When I checked her body awareness
she was beginning to get stiff in her legs, so I had
her run to her safe place. There she began to
associate her irritation to the Arab, and her
friends. She then realized she didn't think it was
at all funny. Her irritation towards them increased,
becoming anger. Remembering the cultural discussions
we have had she became clear that this older Arab
wasn't joking, but actually testing the waters to
see how far he could go. She became angry her
friends went along with him, and irritated with
herself for not stopping it. She had been afraid not
to go along with the joke, afraid she'd dampen the
group's mood.
The therapist must be able to accept a client's
displaced feelings, and at the same time keep aware
of the bodily signs of trauma. If I had begun to
discuss or argue with R about the direction of my
questioning, much would have been lost.
I had her go back to the scene, hear the "joking"
and say "STOP, this isn't funny!" - and then run to
her safe place. Her sense of power increased. I
asked her what she might have liked to say. "I'm not
for sale! I'm going now!" I had her go back to the
scene, sense it in her body, say her words, a couple
of times, and then run to her safe place.
She now realizes that already the day before the
rape, the sexual atmosphere was uncomfortable for
her. She wonders how she could have been so naive. I
point out her personality tendency to hold back
anger and try to make jokes and peace at the cost of
her own feelings and how she was already, from her
upbringing, used to holding herself back, being
one-down, and not making waves.
Here her orientation resource is increasing both
from increasing memory and emotional association to
the trauma, and in gaining understanding into her
personality makeup. Some trauma clients might need
to loosen a stiff neck to physiologically increase
the ability to orient. This was not necessary for R
as her neck mobility automatically increased as she
worked with the rape.
It was important to work with this incident, because
it was a place where she had seriously cut off her
orientation to danger, which may have made her more
vulnerable to the later rape situation.
R says she has become more protective. She now takes
care to look over her shoulder and to avoid being
followed at night - all reinforcement to her
orientation and safety.
Therapy Session #6
R states that she can only afford this session
and the next two. I remind her of our contract that
she will work with the trauma until she is finished
and explain it is not good to end in the middle, nor
to rush the process. She agrees that if more
sessions are necessary, she will seek further
assistance from her work.
She's been feeling fine, and wonders if it is
resistance, or that the effects of the trauma have
actually lessened. She hadn't been nervous about
coming to this session.
We agree to focus on when she met M and approach the
actual rape. M's tone was very friendly, non-sexual.
He offered to show R and her friend around the city.
I ask if this is normal, both because it is out of
my experience to meet such foreign friendliness, and
because I want to explore her orientation at that
time. R explains that in the '70's it was common for
foreigners to offer guidance to tourists without
expecting anything except the pleasure of sharing
one's country. She had done it herself!
R's friend declined the offer, but R accepted. M
showed her around the city. R was careful not to let
him buy anything for her (he wanted to buy her a
necklace, which she bought for herself) - not to be
in his debt. We agree this was smart! M sometimes
held R's hand, but R believed this was platonic. I
point out that R's considerations - not letting him
buy her trinkets and allowing the hand holding
because it seemed platonic - indicate that she was
somewhat on watch, and somewhat discounting what
could have been important signals. We discussed this
to increase her orientation.
M offered to show R a beautiful ruin outside the
city. She agreed. Everything was fine until, on the
way back to town, the mood changed. A friend of M's
drove by in his taxi and offered them a ride. R
didn't like it when they spoke Arabic and she
couldn't follow the conversation, especially when
she believed them to be arguing.
The taxi driver ran a red light and the police
stopped the car. When they saw a western woman with
the two Arabs, they accused her of being a
prostitute and wanted to arrest her. M defended her
and convinced the police she was a tourist and they
let her go. R was very scared. This is an important
event as it was here she gained trust for M, as she
felt he protected her from arrest. As we explore
these memories, her legs periodically stiffen and I
have her run to her safe place several times.
As a rule of thumb, it is better to have the client
run many times too many than one time too few. But
there needs to be some ANS activation before it can
be relieved in running.
M then asked if R would like to see how he lived.
Never having been in an Arab country before, R was
very interested to see how he lived, and assumed the
taxi driver would drop them off. But to her chagrin,
he came with them to the apartment. She began to get
nervous and asked to be taken back to her hotel.
At this point M announced that he would have sex
with her. The taxi driver wanted sex with her too,
but M said he would protect R if she would
cooperate. M told her to take off her clothes and
lie down. He then put his hands around her neck. R
went dead in her body. She feels this deadness, also
now, as she lies on the mat.
We are now at the center of the trauma, the place
where she believed her life to be in danger. This is
where she went dead in her body. This deadening
response is common in trauma. It is a survival
reflex of the ANS and can appear as either a stiff
paralysis (as we've seen in R's stiffening legs) or
as a flaccid collapse (as we see with R now). It is
the same biologic reflex an animal of prey will have
when captured by a predator, like a mouse captured
by a cat (Gallup and Maser 1977).
I structured the next steps with R's agreement in
an attempt to help R out of the deadness and restore
a sense of power and control. I instruct her to
select something she can use to symbolize the man's
hands (not me or her helper!). R chooses a rolled
towel. She lays the towel on her throat and has a
strong memory of his hands there - I instruct R to
allow this experience only for one or two seconds.
She is then to cast the towel off, yell any
appropriate words, and run to her safe place. She
throws the towel yelling, "Get your hands off of
me!!" and runs with flight reflex fully engaged.
This time when she gets to her safe place she is
crying and shaking. When she calms, she is proud.
After a pause, she agrees do it again. This time she
is more spontaneous, more proud, more tired, and has
a greater sense of control. She is also relieved.
She wants to repeat the sequence, but is too tired.
We agree we will come back to it.
This was a turning point in R's therapy. The rest of
her therapy will be easier.
There are several important principles to discuss
here. First of all it is critical that I allowed R
to choose a symbol to represent the rapist's hands.
It is not a good idea for the therapist to come into
a role where s/he could be confused with the
offender. There is potential for re-traumatizing the
client when therapist and perpetrator become
confused. In addition, the client needs a sense of
increased power and control, not another fight that
could risk re-traumatizing. With regard to the
threat and deadness, I only want her to taste it,
not become dead again. Having her sense the threat
and deadness only a couple of seconds and then
react, makes it possible to turn the imprint of the
trauma around. It also gives the client a greater
sense of control that she is in charge of the
process: confronting her fear, choosing the symbol,
determining where it should be placed, reacting
where reaction was not possible before. Lastly,
getting in touch with how and when she went dead,
experiencing the deadness, being able to come alive
and react, and then release her fear through crying
and shaking will contribute to a reduction in the
ANS activation that has contributed to her traumatic
symptoms and kept a sense of deadness in her body
and life.
PART III
Therapy Session #7
R has a cold. She reports feeling more confident.
She's more assertive, especially at work - with both
colleagues and clients. She accepts her opinions,
and moods more readily. She feels more connected
with herself and less swayed by others. She's not
had any anxiety with clients.
R's view about the rape has changed. It has less
impact. It happened, but she doesn't feel fear or
ill when she thinks about it anymore. It means less
to her life now. She doesn't feel she is repressing.
She has better judgment about which clients she will
and won't accept. And she has not had any weird
encounters with strangers on the train or bus.
She had felt good since the last session, and she
had a lot of energy.
A lot has changed since the last session. It is
tempting to think that it is this last, dramatic
session that has created such change. But it is
actually the build up from all the work that has
gone before that culminated in that session. It is
easy in somatic trauma therapy to put too much
emphasis on the dramatic, active sessions and
discount the value of the careful discussion,
integration, association, body awareness and contact
between client and therapist.
We agree to work further with the rape scene. She
asks, "why did I take off my clothes and lie down?"
An area of guilt. She answers herself: M had a
friend in the next room and threatened he would also
rape her if she didn't cooperate. Her hands become
warm and sweaty as she talks about this, there are
prickles at her inner knees, her feet are cold and
she feels discomfort in her inner thighs.
I suggest she place a pillow between her knees and
slowly squeeze it to build up tension in the thigh
adductors. The left adductors feel "dead" and the
right feel warm (according to R's Bodymap®, her left
adductors are slightly resigned - flaccid - and the
right are resource filled - slightly tense). As she
squeezes the pillow the left adductors begin to
liven, and then to vibrate, and it gradually becomes
easier to get the muscle to tense. She is cold in
her calves and the skin feels creepy, she gets tense
in neck and shoulders (muscles associated with
orientation).
Certain muscles react to trauma with flaccidity - a
physical sign of deadness or resignation. R couldn't
stop M from raping between her legs and the
adductors (muscles that pull the legs together) gave
up trying to stop him. Working with tensing these
muscles helps re-develop her resource to hold her
legs together, and protect her genitals.
After building up R's contact in her body, we go
to the traumatic scene where M tells her to remove
her clothes and lie down. At this point R can feel
she goes dead in her body and I have her run to her
safe place. Here she talks about having been in fear
for her life. She also expresses guilt she feels -
it was stupid to get into the situation. And she is
also disappointed she didn't get psychological help
sooner and has waited till now to work on it.
Grieving is an important part of trauma therapy. How
hard it was, how scary it was, how hard it's been
since.
Her hands were warm and feet cold. I encouraged
her to feel this temperature split - focus on both
sensations at the same time. When she did this she
felt a split in her body. It was a familiar feeling
that she recognized from times she has had sex when
she didn't want to. She felt leg-less, ice cold and
rejecting. She talked about sex vs. violence. She
thought about how it was for M to be sexual like
that. She felt she understood him better and felt
less anger, but thought he was pathetic. She caught
herself being too understanding and wanted to feel
her anger.
It is often very productive in somatic trauma
therapy to have the client feel opposing sensations.
This "splitting" is related to dissociation,
bringing these splits into awareness is usually an
aid to association. In this case R associates these
sensations to her current life. Here R also makes an
important distinction between sex and violence. When
dealing with rape, this is an important difference
to understand. Rape is an act of violence, not sex
(Brownmiller, 1975).
R was still experiencing some temperature split
in her body. I suggest she return to her memories of
the rape scene. R now remembers that she didn't just
lie down. - she protested and M threatened her
again. She remembers his eyes got wild and he
grabbed her throat. It was only then she said "ok".
She had felt trapped and feared he would kill her,
and that no one would know.
With the aid of her helper, R came to see she had
been naive. R had grown up learning to always be
polite and sweet and to not expect people to hurt
her. We discussed cultural differences - I'd grown
up learning to never talk with strangers. We talked
about "healthy paranoia". R warms in her legs, but
her feet remain cold.
It is important to discuss cultural differences.
Here we are also addressing R's character pattern of
always being friendly, agreeable and helpful.
R had hoped this would be her last session, but I
insisted there be 2-3 more times explaining there
are some important aspects of the rape still not
addressed, as well as somatic signs of remaining ANS
activation. She agreed.
Even though much in the center of the trauma has
been dealt with, I still sensed there was more.
There are still body splits as evidenced by her
temperature differences, and there needs to be more
tie in to her life now, especially her sexuality,
and areas of boundary and limit setting. It is
important to associate as much as possible - not
only in mind, but also in body. And it is important
to tie the trauma therapy as much as possible to the
client's life. Additionally, a trauma is not
completely worked through until the client can talk
about it without signs of ANS activation.
Therapy Session #8
R's anxiety continued to lessen and she felt more
aware of strangers when she was out in public - more
orientation.
I suggested we discuss her current sexuality. She
joked about it, and felt tensed in her solar plexus.
There were sexual problems as a result of the rape,
but they seemed better now. We explore this
somewhat. She can lose concentration during sex, but
thought this was not only a result of the trauma,
but also of stress in her life. R appreciated her
husband as a sexual partner. She continued to be
relaxed through the discussion, breathing evenly.
R's body signals told that her current sexuality is
not much of an issue now, so we continued.
R brought up the rape and commented that M had
raped her orally and anally as well as vaginally.
This was new information. We discussed how this
affected her sexual preferences now and then decide
to review the rape scene once more, though it seems
much is worked through. R became clear that when she
went dead, it was in the hopes of surviving with the
least damage,- a usual reason for any defense.
She discussed her confusion about M: good and bad in
the same man. He protected her from being raped by
his friend, he said he "loved" her. And, yet, he
threatened and raped her. He was both sweet and
evil, violent and protective.
I asked if she had such confusion in her life now?
She said that the client who had attacked her at
work was also a mixture - of aggression, desperation
and sex. He had said he only wanted to "feel her
good energy." R says he was a very sweet man and
very polite, not the type she'd expect to be afraid
of.
If R had had a Borderline personality (or had a
strong tendency in that direction), I would have
spent much more time exploring this area of
splitting.
We talked about different publicized cases of
alleged rape: Bobbits, Ted Kennedy's son, Mike
Tyson, and "date rape". This led to a greater
orientation sense, and understanding of how rape
victims become vulnerable to be raped again - if
they don't regain/repair lost or damaged orientation
resources.
R mentioned a man on a train who followed her
recently. She didn't want to reject him, but tried
to ignore him. She was aware there is a boundary
problem here, as she hasn't been effective in
keeping him away. We planned to work with this at
the next session.
"Boundary" refers to one's personal - physical and
energetic - space. The physical boundary of the skin
is constant. Energetic boundaries (i.e., comfort
distances during conversation) change all the time.
Boundary can also refer to the limits we have of
what we will and won't do.
This session focused on integration, understanding
and stabilization - all important processes to
balance with the somatic work. I noted her comment
about being raped vaginally and anally and suspected
this should still be looked at.
Therapy Session #9
We agreed to go through rape scene with an eye to
boundaries. She quickly reacted, said "no", pulled
her legs together and ran to her safe place. I
suggested and R agreed to work with kicking and
pushing in various directions, and ways - saying
"no" with her body. She wanted to kick/push up and
forward and her helper agrees to sit on R's feet and
be pushed up in the air and forward - flying. There
is some fun in this training of a protective
movement.
Training a trauma victim in movements that could be
used to protect herself is an important aspect of
somatic trauma therapy. This is not self-defense
training, but a movement specific training: pushing
and kicking in different positions to wake up
possibly dead muscles or movements. In many cases it
would be appropriate to supplement this with
recommendation that the client take a class in
self-defense. It is not necessary that such training
be done with anger. The purpose is to enliven and
tense, not to express emotion. If a helper is
willing, they can often be used to provide physical
resistance. The therapist must direct all steps and
make sure no one gets hurt.
Kicking behind her, R becomes spacey (likely ANS
activation) and I have her run to her safe place.
She cries that it hurt when M anally raped her, she
thought she'd die. She has a fantasy of cutting off
M's penis. R then gets itchy over her back and
buttocks (deadness coming alive) and asks that her
helper and I scratch her gently over her back. Then
she rests on her back.
The rear directed kicking clearly provoked memory of
the anal rape. This was an important aspect to have
included. Her reaction of itchiness seemed to
indicate a waking up of her skin.
R asks to work with M's strangling her again. We
do, as we did before. Then she wants to push his
hands away. Her helper and I give her resistance,
one to each hand, placing a pillow between our own
and R's hand. She pushes and then runs to her safe
place.
It is the pushing movement that is important -
bringing tension, resource and strength to the
muscles that push away (triceps brachii). It is also
important that she not be in a position where she
will "relive" the rape. By having her push with a
hand each to me and the helper, we avoid a situation
where there is one person over her that she must
push off. If there had been no helper, I would have
likely had her push towards me, but standing up.
Then she wants to push again, and I suggest she
also push with her eyes - as well as her arms -
towards me. We train this, pushing away
contact/making boundary with her eyes. She
recognizes this might help her with strangers who
approach her.
I suggest that R train pushing from her eyes at
home.
Learning to push away and keep out contact with the
eyes can be an important aspect of learning to
protect and hold on to one's boundaries. Many
children do this automatically, for example, by not
making eye contact with people they don't want
contact with. Animals push and challenge with their
eyes in threat. It is accomplished by tensing around
the eyes and having the sense that any contact is
pushed away from the eyes.
Therapy Session #10
R has felt great since the last session, relieved
and relaxed at home. She felt a lot got cleaned out
last time. She's not so stressed.
She has practiced pushing with her eyes. She feels
most successful when she makes her eyes cold and
stares through people. She's not been approached by
strangers since she's tried it.
The last session was profound for her. She'd known
something had been there stopping her; the rear
kicking cleared it. She's taken more space and has
enjoyed more quiet times alone.
R's had success setting clear boundaries with a
difficult Middle Eastern client. Her assertiveness
was well received. She feels she is getting better
at setting boundaries in positive ways. The client
had wanted to kiss her on her cheek in greeting,
which she did not want, but he accepted her limit
that they just shake hands. She feels more
confident.
She had to run for her train after the last
session, and got a little nauseous. She thinks it's
connected to the rape and wants to work with the
nausea. This leads to her memory of being mouth
raped - forced to perform fellatio. We work
precisely with this: how her head had to tip back,
where jaw, neck, throat tenses, etc. I have her push
away a pillow, and say "yuck" as she sticks her
tongue out. She becomes nauseous. We work with this,
with a bucket nearby, in case R throws up. R feels
an impulse to bite. She needs something to bite. She
tries a towel, but it's not satisfying for her. I
suggest sausages that she can bite and spit out; she
likes the idea. (We take a break while the helper
runs across the street to get them. She controls
this process herself: sticking a sausage as deep in
her mouth/throat as she needs to to release the
nausea, then biting and spitting. She finally does
throw up and feels better.
The symbolism here is obvious, although not a
necessary stage in working with rape. I have never
done this with a client before. Here it was
effective in aiding oral aggression that was
deadened in the rape. When working with trauma, one
must be open to creative ideas that apply to the
particular situation. For R this was important, if
unpleasant work.
As we are ending, I tell R I think she is brave,
and as she cries, she can finally feel how hard it
was for her when she was raped and how hard it has
been living with it.
R had expected this to be the last session, but I
insist on one more. I believe that most of the
trauma is worked through, but want to be sure, as
this session was intense. A follow-up is a safety
measure. I would always rather err on the side of
safety - insisting on one or two sessions too many -
than risk missing something important or leaving the
client alone to handle an unpleasant reaction to the
therapy. It can also be important to end with review
of the therapy. The termination process need not be
so long as in a dynamic or characterlogical therapy,
but the principle of appropriate termination is the
same.
(R canceled her next session because she had the
stomach flu - came down with it only a few days
after the last session. A kind of rinsing out, I
think. Could also be an element of resistance to my
insistence on one more session.)
Therapy Session #11 - termination
We discussed R's flu, its cleansing features, and
its connection to the last session which she left
somewhat sad and tired.
R was very irritated I required she come today. I
encouraged her to express this: She didn't feel she
needed it. She had needed, at the last session, to
work with the nausea, now she feels done. But she
does understand the logic of being required to
follow-up the last session and end the course of
therapy properly, and has accepted it.
The rape feels "so long ago", clearly in the past.
Her mode of reacting is no longer tied to the rape.
She is pleased with herself and the therapy.
We do some review to integrate and tie-up loose ends
from her therapy. I ask R what she would do
differently, in a similar situation to see how she
has integrated orientation resources: 1) Be quicker
to realize and react to danger signals. 2) She
wouldn't, again, be interested in a man as
superficial as M. 3) She'd not walk around after
dark or in isolated places with a stranger.
To see how she had changed and integrated
personality and culture aspects, I asked what she
will, now, advise her own daughter when it is her
turn to venture out on her own. R was clear she
wouldn't want to control or forbid an "adult"
daughter, but would strongly advise her: 1) Don't
hitchhike. 2) Stay with your friends. 3) Use your
eyes behind your head. 4) Don't be pressured into
doing something you don't want to do. 5) Best to say
"no" if you are unsure. 6) Don't drink (or smoke
hash or marijuana) with strangers. 7) It's better to
say "no" one time too many, than one time too few.
8) Take time to feel/sense if something is a good
idea. 9) Stay with boys/men your own age.
After thoroughly exploring the above points and
giving space to R to express any associated feelings
to me - both positive and negative - we agreed we
were finished , ended this session 1/2 hour early,
and said "good-bye."
I believe this to have been a successful, short-term
somatic trauma therapy. In 11 sessions, R was able
to expand her memory, associate the sequence of
events during and surrounding the rape. She has been
able to express emotions, enliven dead muscles and
frozen movements, and thaw leg stiffness. She can
now discuss and remember the rape without traumatic
reaction (ANS activation). And her anxiety at work,
the precipitating factor bring her to therapy, is
gone.
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