Doing therapy to heal from Posttraumatic Stress Disorder or Complex-PTSD – is very hard work. It’s hard work, it’s painful, it’s tiring. At first, and for a while, it’s not fun. After a while, further down the track, it gets to be interesting, even exciting, and deeply rewarding, as deep changes are manifest and parts of the self that were buried or blocked can emerge and enjoy being alive.
Doing therapy to heal from PTSD and Complex PTSD requires a commitment to engage in a process in exactly the same way one would commit to taking a degree at university. A commitment to get a degree would require being prepared to attend lectures and tutorials, read a basic reading list, research and read an extended reading list, write essays and/or experiments, study for and attend exams.
In the case of psychotherapy, no-one will demand a commitment of any kind, but if a seeker after healing is really committed to doing what it takes to conquer their PTSD or childhood attachment damage, a commitment to hard work will be necessary. Such a commitment will take place within the self, it may never be verbalised to the therapist. It is a deep, inner promise, a determination, a teeth-gritting bloody-mindedness.
But what does one’s willingness to engage in this therapy process actually require? Ideally, turning up regularly for therapy sessions, having the courage to engage in self-examination, coming back to the next session even when the last one felt painful and confronting, continuing the process of investigation between sessions, becoming observant, questioning, curious, analytical and open-minded, doing your own research in books, on the Net and in the community to understand the psychological, interpersonal and medical issues around trauma and healing, and finally, being willing to externalize your internal world through writing, drawing, diary-keeping and any other form of expression that is right for you.
Note that I have not included any formulas or requirements about the contents of a therapy session. What happens within the session in the therapy room is unique to each dyad of therapist-client. It is a real relationship, albeit a therapeutic one, rather than a friendship. The relationship usually builds upon a gentle opening phase in which both parties get to know and feel comfortable with each other, the focus mostly being on the client and her/his needs. Gradually the ‘work’ unfolds, driven by a combination of the client’s personality and goals and the particular type of therapy (i.e., talking psychotherapy, hypnotherapy, gestalt, psychodrama, psychoanalysis etc.).
Contents of this Page
What is Psychotherapy?
Why is the psychotherapeutic relationship so important?
But it’s not a real relationship! The therapist is just being paid to listen to me!
How to have correct closure to the therapy relationship
Two divergent approaches to psychotherapy – and where they meet.
What is Psychotherapy?
Psychotherapy is the term generally given to the type of therapy needed to heal from long-term psychological damage to the systems of the brain, affecting mind, body and emotions. It differs from ‘counselling’, which is a kind of therapy, generally more short-term, that is more likely to deal with current problems requiring immediate strategies and solutions.
Psychotherapy will deal with current problems as well and will offer immediate strategies and solutions, but it will combine those ‘counselling’ techniques with psychotherapeutic techniques that address deeper issues within the self originating in childhood, adolescence or early adulthood. It is often referred to as the ‘talking therapy’, but that is an incomplete description. Psychotherapy can combine talking with many other modalities of treatment, toggling backwards and forwards between talking, and feeling work, art therapy, gestalt, sandplay, emotional release work, hypnotherapy, somatic (body) work, psychodrama – in other words, any techniques that are needed to help the client work through their issues.
At the core of the psychotherapy process is the therapeutic relationship, i.e., the relationship between the therapist and the client, as well as the three-part relationship between therapist, client and the space they work in. Research has shown very clearly that at least 33% of the effectiveness of psychotherapy is grounded firmly in a positive and well-functioning therapeutic relationship. The same research has shown that the type of therapeutic modality (i.e., psychodynamic, psychoanalytic, hypnotherapy, solution-focussed, gestalt and so on) is not as important as the quality of the therapeutic relationship. The importance of this finding cannot be overestimated. In every reputable book or website on the subject of psychotherapy, you will find the same refrain – safety, trust and control – these are the bottom line requirements for a person to be able to engage successfully in a process of deep self-examination and change.
Many years ago I read a chapter about psychotherapy and the therapeutic relationship, which gave me a definition that has formed one of the key foundations of my therapy practice. The author described psychotherapy as an agreement between two people in which one person will act as the listener, companion, guide and teacher where necessary, and the other will be the one seeking to change their life. The one taking the role of ‘client’ gives the therapist a mandate to carry out this function of listener and companion. But in all other respects they are equal, just two people working together to achieve this goal.
Such an agreement carries with it a responsibility on the part of the therapist, to never betray the trust this arrangement requires, to keep the therapeutic space safe, to not disempower the ‘client’, withhold information or assume authority over her. I find it is easier to avoid those mistakes if I hold the above definition firmly in my mind.
Why is the therapeutic relationship so important?
Anyone who has attempted to confide in another person will know how vulnerable they feel as they do this, and how easily the other person can hurt their feelings with the wrong response. This vulnerability is at the core of our personal relations with other humans, and yet, despite all the difficulties, our need for interpersonal relations is wired into our DNA and into the structure of our brains.
For many people who seek help through psychotherapy, there have been negative and hurtful experiences in relationships during the formative years of childhood or adolescence. These hurts don’t just leave painful feelings and memories, if severe enough, they actually alter the development of the brain, specifically the ‘wiring’ of the neural network and the flow or passage of energy and information throughout that network. This flow of energy and information throughout our brain is what we call ‘our mind’.
For the most part, the developmental damages to the neural network happen within relationships with other humans. Even when the initial trauma is external – say a car crash or witnessing a violent crime – the aftermath, the ability to debrief the experience with a safe person can be successful or a failure. Our brains have evolved to need interpersonal intimacy for emotional health. The point of all this is that when damage to the healthy working of the mind is caused by failures of relationship, the healing of that damage must take place within a relationship, only this time, within a healthy, safe and nurturing one. There are certain tasks of healing for the mind that can only be accomplished within a relationship with another human. And this basic understanding must be the cornerstone of any therapist’s practice.
But it’s not a real relationship – The therapist is just being paid to listen to me!
This is a common feeling experienced by people going to see a therapist. It feels really disempowering, almost humiliating, to feel that the only reason that person is sitting listening to them is because they are being paid to do so. And that probably means that they don’t really enjoy doing it, they’re just making the necessary sympathetic noises.
To any person in the client role who is reading this, I suggest a different way of looking at it. The therapeutic relationship (as it’s called) is indeed a real relationship. But the nature of a ‘relationship’ between two humans is that both parties get their needs met. If only one party gets her/his needs met, the relationship will eventually break down. It may keep going, but it will no longer be an equal and functional relationship.
Some therapists (and other professionals) choose to see a client pro bono (no charge). For those professionals some pro bono work is seen as a way of giving back to the community, and is a choice they make. But no professional in private practice would do their work free for all or even most of their clients, unless they were in the very privileged position of having all the material needs in their life covered and secure and wanted to give to their community without personal reimbursement (as is the case for monks and nuns). In this case, such a therapist would still be getting their needs met, but their needs would be of a more spiritual and altruistic kind. After a day’s work, they would know that they had fulfilled their need to help the needy.
However it is absolutely fundamental in nature that relationships are formed to meet the needs of both parties. This is also true of the therapeutic relationship. For the client’s needs to be met, the therapist must put aside her own need for emotional sustenance, her need to share her own experience and be heard, even her need for the other to consider her feelings. In return for putting aside these normal interpersonal needs, the client gives the therapist something that will meet her material and survival needs, in the form of some money.
Thus the relationship can remain balanced and functional, with both parties feeling that their needs are being met.
Again, for someone in a client role who is reading this, please understand that therapists gain a great deal more than just money from their relationships with their clients. I have heard many therapists comment that they learn so much from their clients and that their clients are often their best teachers. But that is a special extra, for which therapists are grateful when it spontaneously happens.
How to have correct closure when it’s time to finish Therapy
The following discussion by Ryan Howes in the online magazine “In Therapy” covers the topic of finishing therapy. I recommend that any person who is in therapy reads this four part article. I don’t necessarily agree with all of the approach that Howes recommends, but I do believe that if the subject of the ‘termination phase’ is mentioned, it should be right at the beginning. Once therapy is well underway and the client feels comfortable with the therapeutic relationship, it is probably too late to raise the issue, as there is a real risk that the client’s feelings of security will be damaged, and what they may hear is ‘oh, she wants to get rid of me’ or ‘oh, she thinks we should be finishing’.
Here is an extract from Howes’ introduction:
“Clients (and therapists) who avoid the termination process are missing out on some of the best material therapy has to offer. For example, many issues clients raise in therapy include an element of loss. During termination, therapy becomes a laboratory for experiencing, processing and coping with those feelings first hand. What kind of model is therapy if we preach dealing with and accepting loss, but practice denial? Can we rationalize spending a year working through grieving a loved one, yet end our relationship via voicemail? Since all therapy must come to an end, shouldn’t a high quality ending be part of each treatment plan?
Termination is a time to evaluate the work you’ve accomplished, celebrate the progress, talk about which goals weren’t reached and explore any disappointments with the process. It’s reminiscing, an exit interview and saying goodbye wrapped up in one. Sometimes this overview helps it all come together, as seeing the work in the rearview mirror lends perspective. Insights like “Ah, I’m glad you didn’t tell me what to do,” or, “That explains why I felt frustrated sometimes” are common to a good termination. Yes, sometimes this discussion opens a new can of worms, potentially resulting in more therapy. But it may be a can worth exploring.
We don’t have enough good endings in life. The nature of therapy and strength of the relationship should provide clients with this one final gift: a corrective emotional experience regarding endings. Clients and therapists who avoid it are depriving themselves of the insight and healing the termination phase provides.”
Terminating Therapy, Part I: What, Why, How?
Why we fear the end of therapy
Post published by Ryan Howes PhD, ABPP on Sep 30, 2008 in In Therapy
Terminating Therapy, Part II: THE IDEAL TERMINATION
Terminating Therapy, Part III: The Not-Quite-Ideal Termination
Terminating Therapy, Part IV: How to Terminate
Two divergent approaches to psychotherapy – and where they meet
We are talking about paradigms here. The Positivist paradigm led into what can be called “the medical model” of psychological therapy. It is most likely to be found in the offices of psychiatrists and clinical psychologists, and frequently finds expression as Cognitive Behavioural Therapy. Terminology is heavily medicalized, patients are given assessment forms/questionnaires to fill in and labelled with diagnoses drawn from the DSM-V. This is a generalisation of ‘medical model’ clinical psychiatry or psychology, but it does give a brief picture of the Positivist paradigm. This does not mean that all psychiatrists and psychologists practise within such a paradigm. Many choose to work as ‘psychotherapists’ within less medicalised parameters.
The other paradigm I wish to describe, because it’s the paradigm in which I work, can be called the “participative/collaborative model” of psychotherapy (terminology drawn from research paradigms), and is often referred to as a “psychodynamic model”. This model rejects the traditional doctor/patient dyad, which historically is hierarchical and patriarchal, and founded on a long preference for knowledge being kept in the hands of those in authority, while the ‘patient’ is expected to ‘follow the doctor’s advice’. A ‘participative/collaborative model’ works on the basis that therapist and client (not patient) are equal partners in the project and that knowledge is shared. It presupposes that the client will take a very active role in their treatment and may have full executive control of the therapy and its planning, if they wish (and some do wish). Again, this is a generalisation, and I acknowledge that there are gradations of these paradigms along a continuum. I am simply outlining a duality within the psychological therapy field that I have witnessed very clearly.
One of the arguments put forward by the psychiatric profession to discredit psychotherapists who are not trained psychologists, is that (and I quote from the meeting at which representatives of psychiatry vetoed the admission of psychotherapists to the Medicare or Workcover systems) ‘you don’t know what they are doing in their therapy rooms’. What was meant by this is that psychotherapy has no umbrella system of accountability (such as the AMA or APA). There are several professional bodies in the field here in Australia (ACA, ANZATA, ACATA and PACFA to name a few), but they have little power to ban a practitioner who breaks the ethical or clinical rules.
This is a stumbling block for psychotherapists, for sure, but at the same time, the situation of deregulation has its upside, and has allowed models of therapy to develop that are wide and inclusive of the more ‘numinous’ elements in the human experience – spirituality, creativity, intuition, deep compassion, non-judgementality, fluidity, being able to sit comfortably with the not-yet-known. The other area of human experience that is allied to these categories – is Emotion, and that is an expression that does not seem to sit comfortably with the medical model paradigm. The ‘deep emotional release’ work that is part of the trauma model tends to be offered in the alternative psychotherapy practices.
Where do these two systems meet?
They meet in the field of Interpersonal Neurobiology, a field of knowledge pioneered by Daniel J. Siegel (building on the early neurobiological work of van der Kolk, Schore and others) in which evidence-based science and psychodynamic psychotherapy combine in complete comfort. Interpersonal Neurobiology finally gives us the language and biological understanding of the ‘feeling – relational – intuitive – creative – conversational – emotional’ nature of the deep, long-term psychotherapy that leads to profound changes and healing in terribly wounded people.
More on The Healing Journey
Essential Issues in Trauma Therapy