Counselling a Client with Trauma from Childhood Abuse

This article is a composite representation of therapeutic work with clients at Counselling Twickenham who present with symptoms of trauma. It is in no way meant as a transcript or accurate record of an actual conversation that ever took place.
Trauma is described by Judith Herman (1997) as a catastrophic event of overwhelming force, which renders the victim helpless – such as an act of violent abuse, war, captivity, rape or a life-threatening incident. This article refers to traumas that result from childhood sexual abuse by a known and trusted caregiver. The symptoms of trauma are often very disruptive to everyday life and range from flashbacks, intrusive memories, nightmares, dissociative states, fear of intimacy, panic
attacks and depression (A.P.A. 2000). Here, is an outline of a client and her presenting issues, using a composite of examples from counselling sessions, especially edited and recomposed to protect the identity of individuals. I discuss the process – synthesising a blend of theory, reflection and supervision; referring to an integrative theory which informs therapeutic practise as a therapist. This acknowledges humanistic values which validate the individual’s subjective experience, whilst honouring the interconnectedness of clients within a network of family, friends, community and culture. This is because intimacy and relationships are often the first things to snap under the strain. As Herman (1997) says the consequences of trauma for the victim is to breach the boundaries of trusting relationships, family attachment, friendship, love and belonging. The article draws upon Object-relations theory, since it recognises that people are essentially relationship-seeking, while valuing the importance of attachment to the therapist who offers the client a transitional experience of good enough care-giving (Winnicott, 1963). It also attends to the client’s unconscious processes as a tuning-fork for understanding what has been communicated between us, often as a result of transference from memories past onto our present relationship (Clarkson, 1989). For example, at first a client may unconsciously regard the therapist as a potential abuser, because her memories of previous close relationships have taught her to distrust intimacy with others. But later she may come to regard the therapist as a trusted and nurturing figure. This is when growth and healing that takes place in the space between therapist and client; as they collaborate on building a relationship of trust and repair in a safe environment (Jacobs, 1989). Finally, it emphasises the quality of the therapist’s empathic attunements to the client, resulting in a capacity to regulate emotional states and a growing acceptance of bodily experience; rather than persistent modes of anxiety, fear and avoidance of the ‘embodied self’ (Rothschild, 2000).

The Client in Focus: The client discussed here is not based on an actual person or real client, but the interaction is intended as a representative scenario of therapeutic work in general with clients and the script is only representative version of the way therapists work with client. In this scenario the client presents with symptoms of chronic trauma after being sexually abused by his step-father. As an adult he seems to be stuck in a repetitive cycle of victimisation, suffering repeated attacks by significant others (e.g. his spouse and/or children) resulting in despair and helplessness under extreme stress. This escalates into recurring patterns of anxious arousal and withdrawal from the world; as well as suffering intrusive memories, flashbacks and prolonged periods of dissociation. Even when no direct threat is evident, the client may find himself prone to a series of traumatic reminders (such as smells, sounds or frightening images) which trigger intense emotions and thought processes that threaten to disrupt his being and open up old wounds (Van der Kolk, 2007). In the presence of family the client may ‘walk around on eggshells’ and feel anxious ‘not to rock the boat’ for fear of being abused or abandoned.

Traumatised clients often experience intense terror because haunting memories appear as if they were real events. Under these conditions, clients are prone to panic-attacks, as well as episodes of paranoia, depression and anaphylactic shock. At crisis-point, these experiences reinforce a constant state of fear about survival; fuelling dark fantasies that they are being stalked and unable to accept intimacy or support from loved ones. There is also a sense in which the client feels complicit or responsible for the original abuse. Victims of sexual abuse are often conditioned by their abuser in childhood to normalise their experience, convincing them that they shared a relationship of intimacy and love. And since they know nothing better and are afraid of being exposed or losing their only caregiver children are compelled to acquiesce. But as adults, clients may become caught between love and hate for their abuser. Part of the repair work is to acknowledge this and disentangle complex feelings, without robbing the client of their faith in their ability to protect themselves. Very often clients fear not being believed because the fear of speaking out, is often what the abuser exploited to reinforce their helplessness. It is vital that both therapist and client repair this breach of trust as they work together; slowly developing the client’s transition towards self-acceptance and a new experience as a survivor.

I have worked to support clients with patience, empathy and compassion as they learn to make contact with their body, deepen their sensory experience of the world and regulate emotional states by tracking their response to fear-triggers. This helps create a wider ‘window of tolerance’, as they learn to overcome panic attacks, flashbacks & paranoia during times of impending threat (Ogden, 2006). This slowly leads to clients to assert their needs by speaking out, protecting themselves from attack & drawing appropriate boundaries between themselves & potential abusers. 
Process: In the script below is a female client (a composite version of a client), who has just associated a particular smell of aftershave on the street with her abuser as a child. This triggers a panic attack and a flashback to previous memories.

T:  As those…emotions arise for you. What are you tempted to do?

C:  Push them back down again.

T:  Where?

C:  Down here. To bury them deep inside so I can’t remember.

T:  As you recall that smell do you think you’re capable of tolerating those emotions, right at this moment…

C:  I’m not sure. Maybe.

T:  What I’m hoping to do here is…let them rise slowly, so you have a sense of what they are like…but don’t allow them to

overwhelm you…You may stop at any time by raising your hand…Perhaps you might learn to monitor them step-by-step.

C:  Just thinking about that smell…[Clears throat]…sucks my breath away; I still panic…I still get that sinking feeling…of being

physically sick.

T:  What would it be like to breathe as you’re feeling that?...slowly and deeply…because I sense you holding onto your breath

when it’s happening. A lack of air might be making you feel dizzy and put you into a spin...As you take in more oxygen

maybe you can regulate the body’s sensations a little better...[Client starts breathing more deeply]...I suppose one of the

first ways forward is to allow the body to do some of the work.

C:  Right now I want to disappear…It felt like that then…like trying to find hiding places in my head, as he came for me. I’d

forgotten that.

T: Try to say some more?

C: I forgot I used to hide…sometimes I took a knife with me, but I never had the guts to use it.

T: I think you did the best you could. [silence]…Why do you think that memory’s just come up?

C: I don’t know...maybe it’s a reminder that I can protect myself if I want to.

In the moments before the therapist's question (T), the client has been struggling to tolerate intense feelings of anxiety, panic and fear, triggered by a familiar odour of aftershave which evoked by painful memories of his abuse. She has also associated these mental states with intrusive memories and bodily sensations experienced while inhaling the abuser’s odour as she was being suffocated during episodes of abuse. The therapist notices the client’s breathing has become increasingly shallow and infrequent, until she finally holds onto her breath and swallows hard. Usually this is an indication she is about to enter a dissociative state. Before leaping to her rescue, the therapist senses she is holding back intolerable feelings associated with those memories, in order to avoid being overwhelmed. Her response confirms this. However, they have been working hard on expanding his ‘window of tolerance’ (Siegel, 1999) The therapist is gently inviting (T) her to track her bodily sensations as she begins to breathe more easily. It is suggested by Ogden (2006) that helping clients to stabilise bodily responses to fear and arousal, such as under-breathing (or hypoventilation), can often increase the client’s self-awareness; assisting them in reclaiming psychological equilibrium as terrifying memories threaten to overwhelm them. By continually developing the client’s awareness of internal barometers – such as breathing, heart-rate, muscle tension and perspiration – she is learning to regulate his internal states and mobilise the body’s defensive reactions (Ogden, 2006). In this instance it allows the client to make a connection (C) with memories of abuse which would otherwise flood her with intense emotions and sensations which cause bodily dysregulation (Schore, 2003). The client (in C) has also associated his own renewed capacity for emotional regulation with a past memory of trying to protect herself during an episode of abuse. It is therefore vital for me to honour (T) the client’s creative adaptations as a child by hiding from her abuser. Having discussed it in supervision I believe this kind of validation helps reinforce the client’s self-functioning; as well as create a bond of trust to strengthen our relationship (Kepner, 2003).

T: I wonder if…as some of those old feelings…bubble up to the surface, the body’s also remembering…

C: Not sure…but I feel strange sensations.

T: As we create awareness of those sensations and the links with the past…something just gets released...

C:   [The client goes into deep silence and her eyes appear to glaze over as if she has withdrawn into the distance]

T:   …Where are you now?

C: The garden.

T: What’s there?

C: Shrubs and trees…they make better hiding places...

T: When did you go there?

C: When I heard him calling me.

T: What do you think the hiding’s about?

C: So he couldn’t find me.

T: Does that tell you anything about you as a child?

C: I tried the best I could.

T: Even to the extent of finding better hiding places...I think that it’s really brave of you. Try to hold onto that…[prolonged

…What’s happening?

C: [Client is crying]...Made me realise how scared I was.

T: Anything else?

C: Yeah...I feel good that I tried to hide...proud even...[She smiles]...I’d like to take that child and hug her hard and say ‘Well

done kid’...[She laughs and looks at me with sad eyes]...

T: Perhaps you can! Right now.

C: [He hugs herself and laughs again, with tears in her eyes]

As the therapist (T) continues to explore how the client’s awareness of her bodily responses to threat are linked to his emotional states and breathing, she seems to develop a felt-sense of safety which releases further memories without overwhelming her. This learned ability to self-regulate and develop her own emerging boundaries also pushes her deeper into relationship with her body. However, as the therapist is observing the client’s posture changing; some muscle tension returns and she sits back slightly, staring into the distance with glazed eyes. Although, this appears neutral, it is often a sign that she is entering a dissociative state and my ‘internal supervisor’ informs the therapist that this is a benign regression (Casement, 2006). The therapist sees a slight smile on her lips and hear her breathing more deeply. So rather than call her out of this state, the therapist asks her where she has gone (T), while staying with her experience and providing a safe holding environment to explore her memories. Now the client is reminding himself that as a child he did not merely acquiesce to the wishes of his abuser, but sought to hide and protect herself from harm. This is a newly acquired sense of self-preservation, which means her narrative is slowly changing from one of submission and victimisation, to a story of how she tried to survive by ‘hiding’ from her abuser. The therapist asks if this tells her anything about the child and she replies that she ‘tried the best she could’. This is the first time she recognises her ability to protect herself. As T tracks her memories further, we discover she feels proud of that child. Later, in supervision I discuss how limbic systems in the brain trigger a survival response to trauma based on fight, flight or freezing (Siegel, 1999). When a person freezes, because neither resistance nor escape is viable, the self-defence mechanism becomes overwhelmed and disorganised; tending to persist as intense states of anxiety long after the trauma (Herman, 1992). Habitually interrupted defence functions, contribute to repetitive cycles of being retraumatised (Ogden, 2006). T is therefore helping the client to reformulate her biographical narrative and integrate this with memories of survival, as a quiet act of triumph.

T: It sounds to me as if that little boy was very brave...and very creative...in all the ways he tried to protect himself...but I can also sense you feel sad.

C: Hm![Client cries]

T: What are you tears trying to tell me?

C: I did try.

T: But you forgot about that time.

C: [Sniffs]...Yeah.

T: Spent all that time...blaming yourself for not trying…but I think...even in those times where you couldn’t prevent what happened...part of you was fighting back...part of you wasn’t letting him in...when you went to the other place. [Client is

crying] Do you feel you ever have to fight back here?

C: Not fight back exactly...It hurts remembering. Things have always been there...just been too scared to remember, so they remained buried...I don’t’ know whether to fight the memories...Or to let them come.

T: Do you have any choice?

C: I’ve hidden them away for so long, I can easily hide them again.

In previous sessions the client has been struggling with a deep sense of humiliation and shame for surrendering to her abuser without resisting or revealing what she did to others. She further blames herself for being seduced by her abuser and having conflicted feelings. It is therefore important for me to seize this opportunity, as a way of letting the client reflect on and rework the emotional conflicts of her ordeal into a more appropriate narrative. This includes her willingness to fight back and thereby transform her memories (Herman, 1992). It therefore vital for me (T1) to acknowledge and validate the child’s brave attempts to protect herself, as well as allow her enough space to mourn the brutality and loss she experienced (T2). As an adult she can afford to be more empathetic and feel a sense of sadness for the child who was abused. T also draws her attention to all those occasions which she blamed himself in previous sessions, failing to believe in her own powers of protection (T4). Then something changes in the client as she seems to withdraw from contact. T is wary of a possible of malign regression (Balint, 1959), in which the client could re-experience a full-blown traumatic reaction leaving her vulnerable & exposed. T lets her know (T4) that her/his questions may seem intrusive and she may want to resist answering them. However, this is a choice point. T could steer her away from painful memories, but it's important for both of them to acknowledge the potential threat the therapist may represent (Van der Kolk, 2007). This would allow her to resist T, to push back and learn to set her own boundaries during therapy. It would also allow the flood of anger, sadness & loss to be brought back within her window of tolerance through self-regulation, learning more appropriate ways of defending herself. The client reminds T (C5) that although it is difficult for her to simultaneously fight and give way to painful memories, she could so easily bury them again, but the significant thing is, she doesn’t.

T: Are you saying that you don’t choose to hide them here?

C: No.

T: So what is it about what you do here that allows them to surface but at the same time you don’t let them overwhelm you?

C: Because I can’t talk about them anywhere else...Because you accept me... [Laughs and smiles]...You want to help.

T: So there’s something about trust.

C: Yeah.

T: I’m glad I can help.

C: [Smiles with relief] I feel protected here. [Cries]

Staying with her choice to resist an impulse to ‘shut-down’ and disconnect with her body, T asks the client (T1) whether there is something about the nature of our encounter which enables her to reveal these painful memories. T is mindful of previous discussions in supervision of how bringing the client into direct contact with me, immediately after revealing traumatic memories may be too much intimacy to bear. In a paradoxical sense this could trigger an unconscious re-enactment of the original trauma between us. By asking too many probing questions, T may come to represent the abuser who demands intimacy with inappropriate advances and then betrays that trust. However, despite her tears, she is holding direct eye-contact with me and T feels she is reaching out, longing to tell T something of special value. Following her cue, T asks (T2) if there is something about the session which allows her to open up without feeling overwhelmed. Her response seems to confirm T's intuition that she is ready to make contact and acknowledge the value of our relationship. This is a genuinely co-created encounter, as she reaches out, letting me know (C2) how important it is to feel believed here and to be accepted from the beginning of our work together. As Herman says: ‘by this stage of recovery the survivor of abuse has the capacity for appropriate trust. [She] can maintain [her] own point of view and [her] own boundaries. [She] has begun to take more initiative in [her] life, creating a new identity. With others, [she] is ready to risk deepening [her] relationships…The deepening of the connection is also present in the therapeutic alliance. There is room for spontaneity and humour. Crises and disruptions are infrequent, with increasing continuity during sessions. The patient has more capacity for self-observation and greater tolerance of inner conflict.’ (1992, p. 205) From supervision discussions it’s possible she has internalised T as a ‘good object’ (Klein, 1998); perhaps the loving biological father she remembers from early childhood before he was lost to a fatal illness.

Conclusion: This was a reparative piece of therapeutic work, although there were choice points where T could have made alternative interventions which resonated with the client’s frame of reference. For example,TI could have stayed with the client’s attempt to resist me and explore her sensations, as she drew up boundaries. It was a real challenge to attune myself to the client’s emotional states without becoming entangled in the residue of trauma. However, the intervention T chose, did help to create a process of internal regulation, by slowing down my own process and tracking her experience to ensure she did not enter a 'malignant regression' (Balint, 1959). T was mindful not to expose her directly to distressing memories of the original trauma with its potential for re-enactment. However by the end of the session the client managed to identify ‘blocked’ sensations and buried memories, as well as associate these with levels of arousal during past traumas. This was a significant step in recovery for the client who is now learning to trust the process more. T is engaging in tolerable contact with her while moving towards an authentic healing relationship.

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