The View from Here: 50 Years as a Trauma Psychotherapist

Pain humbles the proud. It softens the stubborn. It melts the hard. Silently and relentlessly, it wins battles deep within the lonely soul. The heart alone knows its own sorrow and not another person can fully share in it. Pain operates alone; it needs no assistance. It communicates its own message whether to statesman or servant, preacher or prodigal, mother or child. By staying, it refuses to be ignored. By hurting, it reduces its victim to profound depths of anguish. And it is at that anguishing point that the sufferer either submits and learns, developing maturity and character, or resists and becomes embittered, swamped by self-pity, smothered by self-will. (Swindoll, 1985, p. 231)

After graduating from the University of California at Los Angeles (UCLA) in 1957, I was accepted to Pepperdine College's graduate program for my master's degree in psychology. Pepperdine was located in the impoverished areas of Los Angeles adjacent to Watts. Two years later I was appointed as an instructor in the psychology department and a staff psychologist to the Pepperdine Psychology Speech Clinic. I didn't know at the time that I would become a trauma specialist.

Eventually my wife and I adopted a 5-year-old girl from the Los Angeles foster care system. For the first 5 years of her life, she had been placed in five different foster care settings and one adoptive family from which she was removed because of allegations of abuse. I wasn't aware that I was living with trauma at that time.

In 1964, I survived the first Watts riot, which included the loss of a significant friend. I still I didn't know I was living with trauma.

In 1980, my adopted daughter began to act out severely, repeatedly placing her life in jeopardy. We hospitalized her for treatment, believing this to be in her best interest. After 2 weeks of running back and forth from the hospital, my wife and I discovered we could leave for a weekend for some quality time to ourselves. This was a shock because we had been unable to do this for several years because of her long history of emotional problems. The following Monday in family therapy, we told her we wouldn't be visiting on the weekend, which resulted in her going into restraints four times. At an emergency family session where we all met, she had a breakthrough for the first time in her life when she stated, “I don't believe you'll come back.” At that moment, I began to realize what trauma therapy was about.

My family, with two sons and two adopted daughters, a few dogs, cats, rats, and lizards, taught me everything I was going to learn about attachment theory. My development and growth as a psychotherapist has been profoundly influenced by the effects these relationships have had on me.

In addition, the contrast between my experience at UCLA and that at Pepperdine College has affected how I see the role of science in the healing relationship. At UCLA, my training in psychology involved the empirical science of behaviorism, whereas Pepperdine's graduate program in psychology was directed by a faculty trained by Carl Rogers. This established the dialectic between the role of science and the knowledge gained from intuition and wisdom in psychotherapy. I believe understanding this dialogue is essential for us as healers to benefit from science and not lose the benefit of wisdom in a healing relationship. The review here is a reflection of that struggle.

THE VIEW FROM HERE

The field of psychotherapy is plagued by multiple and competing three- and four-letter therapies and their manuals in the attempt to provide “evidence-based treatment” (e.g., EFT, DBT, CBT, EMDR). After more than 50 years of research into psychotherapy, the evidence overwhelmingly asserts that the relationship has the largest effect in outcome studies (Wampold et al., 2010; Norcross, 2002; Wampold, 2001). Wampold distinguished between specific and general effects. He wrote, “Specific effect is used here to referred to the benefits produced by the specific ingredients; general effects is used to refer to the benefits produced by the incidental aspects (i.e. the common factors)” (p. 7). Specific effects represent such techniques as the thought record in cognitive–behavioral therapy (CBT) treatment. All other variance would represent general effects. These general effects could be errors in measurement or other effects that can be attributed to the relationship that have not been measured. This is not to say that specific effects do not have their benefits; rather, the mechanism or agents that produces the observed change is not clearly understood, nor does it produce a very large “effect” in outcome studies (Duncan et al., 2010). I believe this attempt at scientific rigor has occurred in the absence of enough attention to the empirical evidence of what the effects of the therapeutic relationship are in psychotherapy. The need to provide evidence to justify services within the medical model to insurance companies and government agencies has led to policies that demand empirically supported therapies or the more recent evidence-based treatment.

Psychotherapy is an interpersonal process in which information is exchanged between two people for the purpose of healing one of them. In this dialogue, one person (the therapist) is trying to effect a change in the mental and behavioral functioning of the other (the client or patient). For better or worse, both participants will be changed by this encounter.

The field of psychotherapy needs to identify what the “specific effects” of technique are on the patient independent of the more general effect of the relationship itself. Equally necessary, we need to know more about how the general effect (the relationship) produces the positive changes that are observed in our patient. A growing body of research in the cognitive neurosciences may help resolve this issue (Arden & Linford, 2009). However, this focus carries with it an inherent danger to effective treatment. Therapists can become overly invested in the technique and overlook the fact that the largest variance accounting for patient improvement is in the relationship itself.

In a study by Shaw et al. (1999) on delivering CBT in the treatment of depression, wherein both competence and treatment adherence were measured, adherence to treatment was unrelated to outcome. However, when the variables of adherence and competence were combined, the researchers found a significant relationship between competence and outcome. This means that the relationship variable greatly impacts outcome. It also suggests that overly strict adherence to the treatment model may interfere in the relationship. It is my opinion that there is much that remains unknown about what makes for an effective therapeutic relationship. In light of our uncertainty about the specific effects of the relationship, as well as our own anxious vulnerability, having training in specific techniques soothes our anxiety and doubt. Therein lies the danger of putting technique over relationship in our work.

There now exist many studies about relationships that show them to be complex, hard to reliably measure, and yet the largest variance factor accounting for change in outcome measures (Duncan et al., 2010; Norcross, 2002; Wampold, 2001). It is crucial to be aware of these variables and spend as much time teaching therapists these interpersonal skills, as it is important to teach a specific technique. It is also important that we keep their relative importance at the forefront when dealing with competing economic interests. For instance, the fact that a for-profit industry like the insurance companies and managed care influence what is acceptable evidence creates a compelling pressure on many therapists. Our own need for financial security also exacerbates this problem.

PATIENT FACTORS

Many studies have focused on the human potential for self-healing; Carl Rogers emphasized this fact in his study of psychotherapy. Honos-Webb (2005) proposed the patient's expectation, or the placebo effect, as an empirically supported treatment. This factor has always confounded the study of treatment effects. It is a robust effect, supporting the position that intrinsic idiosyncratic individual characteristics are among the factors responsible for change. Patients are anything but passive recipients of treatment. Patient characteristics such as agency, activity, reflexivity, and creativity contribute to the effectiveness of psychotherapy (Duncan et al., 2010). We can conclude that “encompassing spontaneous recovery, self generated change, placebo effects, resilience, post-traumatic growth, and the corrective effects of self-expression in disclosure—humans have a good deal of potential for righting themselves when struck by adversity” (Duncan et al., 2010, p. 88).

RELATIONSHIP FACTORS ACCORDING TO PATIENTS

In 1951, Carl Rogers defined empathy as the therapist's ability, sensitivity, and willingness to understand the client's thoughts, feelings, and struggles from his or her point of view. This factor has been reviewed in many studies and has revealed a median r = .26 for the effect of therapist empathy on outcomes of psychotherapy (Duncan et al., 2010).

Alliance refers to the strength and quality of the relationship between the patient and the therapist. Many studies have shown this variable to be significant to treatment outcomes. Such elements as goal consensus and collaboration are involved in building a strong alliance. For example, Creed and Kendall (2005) found that using language like “we,” “us,” and “let's” as well as presenting treatment as a team effort, helping set specific goals for therapy, and encouraging specific feedback from clients built a strong alliance.

With mixed results, positive regard has been shown to be crucial to therapy outcomes (Duncan et al., 2010). This quality of the therapist is characterized as unconditional positive regard and a deep nonpossessive caring. The therapist's job is to separate the problem behavior from the person and communicate value for the client regardless of his or her problematic behaviors (Duncan et al., 2010).

Genuineness and self-disclosure have also been found to be important in facilitating a strong relationship. Self-disclosure has been found to be controversial because inappropriate self-disclosure can cause problems. However, lack of self-disclosure can leave a patient feeling mortified and rejected (Dalenberg, 2000). Effective self-disclosure can be used to validate reality, normalize experiences, model, and strengthen the therapeutic alliance. However, therapists should avoid self-disclosure for their personal needs. I must admit at times my need to feel I exist in the relationship has caused me to inappropriately self-disclose. Careful observation about the patient's reaction to self-disclosures and encouragement to share his or her reactions to the disclosure is essential. Appropriate self-disclosure can be helpful in establishing trust in the relationship (Norcross, 2002). In addition, the ability to repair ruptures is an important relationship factor. Patient deference, fear of criticism, sense of indebtedness, the need to please the therapist, and fear of threatening the therapist's self-esteem inhibit the patient's disclosure of negative feedback (Rennie, 1994). When therapists fail to attune to these negative reactions and facilitate exploring them in a nondefensive manner, patients can leave therapy.

Research on countertransference points to the importance of the therapist's own psychological organization and ego strength in resolving the therapist's experience of threat and feelings of loss of control when confronted negatively by patients (Norcross, 2002). Patient-to-therapist attachment style can provide important information for the therapist in choosing an effective intervention. Norcross noted that the “people's mental representations of themselves and of attachment figures, whether they are reflected in manner of speech or in self reports, make a difference in terms of how therapists respond to patients and in terms of treatment response” (p. 376). David Wallin (2007) has explored this attachment relationship in depth: “By virtue of the felt security generated through such affect-regulating interactions, the therapeutic relationship can provide a context for accessing disavowed or dissociated experiences within the patient” (p. 3).

THERAPIST FACTORS THAT DON'T WORK

Some obvious and some more subtle characteristics of therapists have been shown to have adverse effects on the relationship in psychotherapy. In the field of addictions, confrontation has been used extensively, and there are consistent findings that this style is ineffective (Norcross, 2002). Making comments that are hostile, pejorative, critical, rejecting, or blaming can produce negative outcomes in treatment (Duncan et al., 2010). Although boundaries can be important, especially in the management of borderline personality disorder, excessive rigidity can disrupt the therapeutic alliance and result in early termination (Linehan, 1993).

In addition, therapists who pigeonhole their patients and treat the diagnosis rather than the person tend to have negative outcomes. A further failure comes from not recognizing ruptures that have occurred in the therapeutic relationship. Furthermore, therapists that do not help the patient verbalize the problem in a warm, genuine, and accepting way will find their patients leaving (Castonguay, Goldfried, Wiser, Raue, & Hayes, 1996).

The management of countertransference is extremely important in that therapists are profoundly affected by the emotional cauldron that exists in the therapeutic alliance. Studies on affect broadcast and mirror neurons demonstrate that our bodies resonate with the emotions experienced by our patients (Siegel, 1999). Indeed, numerous studies on vicarious traumatization show that therapist burnout is related to being in the presence of so much human suffering. Burning out as a therapist results in poor therapy and is harmful for our sense of well-being and self-worth (Pearlman & Saakvitne, 1995).

WHERE FROM HERE

Those of us treating complex trauma should keep in mind the importance of the psychotherapeutic relationship. We are all subjected to pressures to justify our treatment methods to managed care and government agencies. In my position as a consultant to Del Amo Hospital in California, I have been told that Medicare has hired an agency to retrospectively review all charts of patient treatment. The agency will be paid by how many charts are denied benefits. The justification for the denial will be based on medical necessity. Because the definition of medical necessity will include information from studies on evidence-based therapy that do not measure the relationship, this may result in arbitrary denials, more paperwork to justify medical necessity, and poorer patient care.

The reality is, the evidence for the effectiveness of psychotherapy is strong. My brief review of this field leaves me with the impression that we are not focusing enough on the empirical evidence that supports the relationship as the most powerful empirically supported treatment effect. In the pressure to justify treatment for techniques such as thought records (specific effects), we will lose focus on the therapist–patient or relationship variable. Most training workshops provide training in techniques and simply assume that the therapist is competent in the therapeutic relationship. It is difficult for any of us who have spent years being trained in a specific theoretical modality of treatment to understand or accept that the evidence favors the relationship over the specific technique or orientation. The fact that relationship skills are learned implicitly in our early attachment relationships makes it hard to explicitly identify and measure them.

Human relationships are very complicated. We exist in an ongoing narrative cultural context of being. We are a social animal, and our “becoming” is a result of all of the interactions we have had since birth, including the genetic information we have inherited. Studies in the experience-dependent maturation of the brain tell us how crucial relationships are to our narrative sense of self.

History shows the importance of the healing relationship. In all cultures, the healing relationship has appeared in many forms: witchdoctor, shaman, priest, physician, native healer, and more. There is a collective wisdom in these roles. They represent a knowledge inherited from our ancestors. Nearly half a century ago, Perry London (1964) suggested that the current psychotherapists were the new “secular priesthood.” It can be argued that psychotherapists are an epiphenomenon of Western Enlightenment-based cultures (Duncan et al., 2010). Healing through the benefits of a relationship has been present throughout history. There is an obvious connection between psychotherapy and religious healing. We have a myth called the treatment modality; we engage in a ritual with our patient in various settings such as the hospital, clinic, or office and engage in the practice of healing.

Perhaps a major difference exists because of our embracing the scientific model in the search for the “truth.” I believe the practice of psychotherapy is still more art than science. Recognizing that our therapeutic modality is infused with the mythos of our culture should not diminish our ability to practice psychotherapy.

This is the dialectical tension I have lived with throughout my 50 years as a psychotherapist. I have found it meaningful, exciting, rewarding, and purposeful. In our attempt to appear scientific, professional, and ethical we can trivialize the fact that we are engaging in a real relationship. What we do can and does help or hurt. Professional boundaries can be used to protect ourselves from this reality. None of us can be more than who we are, but I would hope we try to grow to become more than who we currently believe we are.

I hope you can enjoy the struggle as much as I have.