
Home Trustees Articles & Information Organisations Dissociation Trauma Attachment Self Harm Sexual & Ritual Abuse Working Approaches Spiritual Dimension of Recovery Books Book Reviews Book List (by Author) PDF Book List (by Title) PDF Book List (by Year) PDF Training Links Membership Contact	Working Approaches Helping to change the world Working with survivors of ritual abuse A Three Phase Approach to Recovery Some Thoughts on Handling Flashbacks and Abreactions in Therapy Postal and Email Counselling Some Reflections on Containment Affect Regulation Skills The Impact of Attachment Trauma on the Helper Are You a Brain Organiser? An Integrated Overview of Functioning States of Conciousness Helping to change the world Over the last 20 to 30 years our society and our culture has evolved through considerable and probably unprecedented change. Nowhere is change more evident than in the fields of micro-technology and tele-communications, with all its implications and impact on our daily lives whether in daily living, leisure or work. There have of course been many other changes, although not all of them quite so obvious. Amongst the changes that have taken place are the increased understanding of our own human functioning and of our needs, both as individuals and as social systems in society.One trend in the past thirty years has been the readiness of people to talk about difficulties in their own life, which has lead to an increase in counselling and other forms of therapeutic help. This trend has made it more possible for individuals who have suffered from more extreme forms of early life trauma and abuse to disclose to others and to also seek help. Ironically, contraction in public services, with limited public health provision and absence of specialist provision has lead many people to seek help from voluntary organisations, churches, independent counsellors or voluntary counselling agencies. Conditions such as Post Traumatic Stress Disorder, Unresolved Insecure Attachment Difficulties, Dissociative Disorders and all the associated relational and behavioural problems may well be amongst the conditions presented to counsellors and carers by some people seeking help or support. There is now real necessity for counsellors, carers and churches to be able to recognise and understand these conditions, if the help being offered is going to be effective and not aggravate the person’s condition with mistreatment or even abuse. This situation is particularly difficult for a survivor of ritual abuse because of the widespread diffidence that exists in the public’s mind about whether ritual abuse actually exists. Denial, disbelief and misdiagnosis are tragically common place experiences for survivors of such childhood atrocities. Despite the increasing number of press reports of varies forms of ritual abuse, and the now quite large number of people in therapy who describe this as part of their background, officially it is still deemed not to exist. This not only creates phenomenal difficulties for survivors but also leaves counsellors, carers and other professionals extremely isolated in their task of helping client through to recovery. Four years ago the ACC commissioned a working party under the chairmanship of Revd David Woodhouse to consider the whole area of childhood ritual abuse, and to come up with some guidelines for the training committee on the sort of training that would be most helpful to counsellors and carers who are working with survivors. The working party decided to make the focus of its report ”Working with Dissociative Disorders” as many survivor of childhood abuse, and all survivors of ritual abuse, would be likely to be suffering from Dissociative Disorders including some who will suffer from Dissociative Identity Disorder (previously known as Multiple Personality Disorder). Other parallel conditions that survivors will experience will include Post-Traumatic Stress Disorder and Insecure Attachment. The working Group decided to also form the “Trauma and Abuse Interest Group” (TAG) as an affiliated group within ACC, as so many counsellors and carers had asked for ongoing information, training, networking and support. TAG now produces a twice-yearly newsletter with articles and information, a contact list, training days and workshops and will be putting a course on at the next ACC National conference in 2003. Subscription for TAG is £10 a year via the contact address at the end of this article. The response of the ACC board to the report has been very encouraging, acknowledging that counsellors need to know about Dissociative Disorders, and should have access to training, support and appropriate supervision. It is very encouraging that the Christian counsellors’ national association is both recognising this area of work and seeking to appropriately support counsellors working with survivors of extreme childhood abuse. More importantly it gives a message to survivors that they are believed, cared about and that hope does exist for their recovery. It also means that counsellors need not struggle in isolation, unsupported by their own national association. Working with survivors of early life trauma and ritual abuse is a complex area of work, which is long term, intense and painful for both clients and counsellor. However with many advances in bio-neurology, clinical understanding is changing rapidly. It is important as carers and counsellors that we can keep abreast of developments and can keep a balance between demonstrating the unconditional love of Christ in all situations and the professional good practice needed in working in this area. The harsh reality is that many survivors cannot find or afford counselling or professional help or get the informal support needed to make the journey of recovery. Of those, who do find a counsellor, some have to face the fact that counselling gets terminated as soon as ritual abuse is mentioned. Although there are many counsellors effectively helping survivors, there are also counsellors who are struggling or whose supervisors do not have the experience in this field of work. For those survivors who turn to the church, it is not easy to speak about their experiences, many still find themselves misunderstood, or worst still, subjected to oppressive teaching or even abusive deliverance for what is a clinical condition. There is a major task to undertake of awareness raising in a disbelieving and punitive world. The medical establishment has yet to fully take on board the clinical implications of Dissociative Disorders and the effects of disrupted attachment. The legal system is unable to accommodate the needs of abused, traumatised and dissociative clients and the Parliamentary system has not once mentioned ritual abuse in either House in the last five years. It is against this background that the very positive response from the Board of the ACC may enable and contribute to an important and much needed public understanding. This includes ensuring that counsellors are equipped and supported in helping survivors to both recover and have a voice, that understanding is increased and that information is shared. ACC can also support counsellors to help churches, voluntary organisations and Health and Social Service agencies to more effectively play their part in survivors’ recovery. In our own small way we can help to change the world. Mike Fisher - Chair of TAG [back to top...] Working with survivors of ritual abuse Working with Clients who are Survivors of early life Trauma, Sexual and Ritual Abuse One of the things that counsellors ask for, from time to time, are guidelines for working with survivors of ritual and extreme early life abuse. Whilst it is important to be careful about over generalising, the following may be helpful pointers in this area of work. There are likely to be three parallel processes of on going work. These are unresolved insecure attachment, post traumatic stress disorder and dissociative disorders (possibly including Dissociative Identity Disorder, referred to as DID) as well as possible co-morbidity with other conditions. The first and foremost thing to appreciate is that recovery from early life trauma and abuse is going to be long term, unlike many conditions that present themselves in the counselling room. It may take many years of regular, and often intense, work to see someone through to recovery. Preparedness from early on to work with someone over a number of years, rather than weeks will be important. The second is that the therapeutic relationship is always important in counselling. It will be even more important when counselling someone who has experienced early life trauma and abuse. It will take time for trust to build up, to the point that deep and effective work can be undertaken. The power of a reliable, consistent, dependable and accepting relationship cannot be underestimated. It will be the vehicle by which the trauma, pain, guilt, shame, fear and anxiety will be processed and resolved. The third is that counsellors will need to develop good “containment” skills. Working with someone who has been through ritual abuse or extreme early life trauma can be experienced as a bit of a roller coaster. The counsellor will, also therefore experience the confusion and dissociation that the client experiences,, and a capacity to stay with the uncertainty will be needed. Most survivors will also have an insecure disorganised attachment pattern, in which they will be experienced as being very ambivalent in their relationship with the counsellor, (or at times avoidant) and, in the “middle phase” of the work extremely dependent. Again it is important for the counsellor not to get fazed by this, but have the capacity to stay with the client as they try to work through their attachment issues. It will be alarming for the client as they risk, possibly for the first time, allowing attachment to take place. It will also be alarming for the counsellor if they have a fear of dependency, or equally unhelpful, if they have a need to rescue. Without a safe, close, accepting relationship it’s unlikely that the client can risk the journey of recovery. If not they will have no choice but to maintain the dissociative defences that are needed to keep such overwhelming pain sufficiently at bay to cope with life’s demands. They will have a highly developed level of hypo-vigilance and of will have learned that being compliant was necessary for their survival. Without an adequate level of effective support the opportunity to address the extent of the trauma and disrupted attachment experience will not occur. In the words of Valerie Sinason, “It’s the relationship that gets individuals through to recovery, not a particular therapeutic modality.” Most counsellors and carers, who work with survivors, would probably agree, that the best source of understanding comes from the person themselves, who has survived the abuse and trauma. I believe, as a therapist, my role is to accompany them on their journey of recovery. Far from having any expert contribution to give them on their journey, I have found that they truly are architects of their own recovery, and indeed they have taught me a lot in the process, including about myself. Perhaps above all else the power of listening in a very attentive and attuned way is the greatest skill a counsellor can bring to someone’s journey. This is not to dismiss the wide body of understanding, or the range of skills and techniques that can help, but without effective listening such knowledge will be ineffective. A particular challenge that will come to counsellors in this field of work will be the fact that the client will be able to “read” the counsellor more easily than the counsellor may be able to read the client. For many survivors their very life depended upon developing very highly attuned insights as to what was going to happen next. Because of this highly developed skill, they will pick up the least little inconsistency or incongruence in the counsellor. They will be aware of the counsellors vulnerability and be able to register any defensiveness in the counsellor, all of which will be an obstacle to them feeling safe enough to risk exposing their pain. This does not mean that survivors are especially difficult to work with, indeed they are often highly rewarding people to work with. It does mean however that counsellors do need to attend to their own “needs” both in supervision and in personal therapy, if they want to avoid such obstacles occurring in the work. It is unfortunately not unheard of to find counsellors who will blame or scapegoat clients who become resistant because they are feeling unsafe in the therapeutic relationship. An awareness of what is happening in the therapeutic relationship will be as important as addressing the ongoing trauma. Self-awareness and personal insight will therefore need to be worked on and maintained, in order to maintain optimal effectiveness. This may be one reason why recovered survivors make good therapists. Another factor that makes this area of work somewhat different is that a fifty minute or one hour appointment once a week is not on its own usually sufficient to keep the client sufficiently stable particularly in the middle phase of recovery. Many clients find they need either longer sessions of one and a half or two hours or more frequent sessions of two or in some cases even three a week. For clients who suffer from Dissociative Identity Disorder, their personality will have been fragmented into a number of parts, known as Alters, as a result of the severity of the early life trauma. This was formally known as multiple personality disorder. This will particully be the case if the client is suffering from Dissociative Identity Disorder especially if there are a great many Alter parts. There are two reasons for this, the first is that there would not be sufficient time to help the “internal system” process sufficiently the current trauma and at the same time give attention to the therapeutic relationship as well as develop internal mechanisms for coping. The second is that the “child” parts will need regularity and frequency to sufficiently attach. Many survivors may find the duration of a week, and certainly a fortnight’s gap too much to cope with in managing their daily life when traumatic memories are emerging. The consequences of insufficient support are that they may resort to less satisfactory coping mechanisms or move in and out of chaos. This is why many survivors of more extreme trauma or ritual abuse and most clients with DID often seek regular telephone or other forms of contact between sessions. If this is going to be necessary, it is much better to plan this in, when it is needed, as part of a negotiated agreement than to leave it too open and loose, as the client will be less sure of where they stand and of what support is available. Boundaries will be an important part of the security for the client and these should be clear, but not overly rigid, as the client’s stability will fluctuate from time to time, and some changes in arrangements may be required. This will need to depend on both the client’s need and what the counsellor feels they can realistically provide. Perhaps the last area to mention is coping with traumatic disclosures. This will constitute the other main challenge for counsellors, particularly if their client is a survivor of satanic ritual abuse. It is not uncommon for counsellors to experience vicarious trauma when working with survivors of ritual abuse. This should not constitute a problem provided that there is good supportive and “containing” supervision. It might be that the counsellor may benefit from some counselling for themselves, or would find it helpful to belong to a network such as the Trauma and Abuse Group (TAG) where they can chat to other counsellors and carers in the some field of work. Mike Fisher Chair of TAG and Director of the Willows Christian Counselling Service Reference “Attachment, Trauma and Multiplicity” by Valerie Sinason, 2002 [back to top...] A Three Phase Approach to Recovery One helpful model for treatment and recovery recognises three distinct stages or phases towards recovery. These can be identified as: Stabilisation and symptom reduction Processing traumatic memories and achieving change Resolution, integration and recovery However in actuality no treatment process moves through this progression in simple linear fashion. There will, at times, be considerable overlap or movement between the stages. There will also be a wide range of tasks that will need to be undertaken in the progression towards recovery. Elements of each of the stages or phases are likely to include the following. Stabilisation Establishing a relationship and therapeutic alliance. Developing trust and setting boundaries. Assessment and mapping of the system (if DID) Developing effective support systems. Achieving a safe sense of physical and emotional being and environment. Developing strategies to enhance order and routine. Developing grounding techniques. Seeking to recognise and manage triggers. Develop sense of containment and coping skills. Assist with changes in cognition and behaviour. Promoting internal communication. Development of safety and internal safe place. Processing trauma and achieving change Managing hyperarousal with cathartic expression of emerging emotions. Reducing trauma with the recovery of specific memories. Facilitating the association of behaviour, affect, senses and knowledge (BASK) Reframing understanding, thoughts and feelings. Processing traumatic disturbance to reduce avoidance and intrusion. Developing alternatives to self-harming, phobias and destructive behaviour. Increasing of comfort, self-nurture, reward and satisfaction. Containing of conflicts of attachment, dependency and abandonment. Reducing dependency on dissociation. Managed reduction of addictive tendencies and self-harming. Changing the patterns of fear, guilt, shame and self-blame. Promoting internal co-operation and collaboration. Development of crisis management skills. Supporting verbal and creative expression. Resolution and recovery Achieving an increased sense of self and identity. Increase in independence and life choices. Achieving new, realistic life perspectives. Association of alters, parts and functions. Possible integration of alters. Resolution of significant conflicts. Expression of post-integration grief. Strategic planning of future life. Maintaining life functions within normal parameters. Reduction in the expressed need of dependency on therapist. A planned gradual reduction in therapy. This list can only be a very basic guide to what can be a complex array of tasks that may need to be undertaken as part of the therapeutic journey. Every individual’s needs and circumstances will be different. Likewise the time involved in making the journey to recovery will vary a great deal. The only predictable factor is that it will be long term. Whilst the first phase can take a long time before survivors feel secure enough to work in depth, phase two is likely to be the longest phase of recovery. Pacing the therapeutic work and the rate that the survivor can manage is important, otherwise “flooding” and destabilisation will take place. Some considerations for Counsellors. Understanding different types of alter personalities and their function. Appreciating the dynamic between alter parts. Understand imitation DID distinguishing features. The implication of transference and counter-transference with dissociation. The importance of the somatic dimension of trauma & dissociation. The relationship between trauma, insecure attachment and dissociation. The value of creative methods and other adjunct therapies. Using Multiaxial Assessment and Global Assessment of Functioning scale Using the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) The importance of recognising patterns and trends. The need to cope with chaos, confusion and uncertainty. The need to deal with one’s own vicarious traumatisation. The importance of keeping one’s own defences at a minimal level. The value of finding the ways of working with each client that are the least traumatising. Appreciating that this area of work is both very simple and very complex. The necessity of supervision, support and therapy for counsellors. Mike Fisher 2003 [back to top...] Some Thoughts on Handling Flashbacks and Abreactions in Therapy Flashbacks are the intrusive ‘reliving of trauma’ - type experiences, common to people who have experienced severe trauma. In most cases, these decrease over time as a person processes the traumatic material, but for those who develop posttraumatic stress disorder or have a dissociative disorder, these symptoms do not improve. They are like pockets of past time, intruding into consciousness, causing the person to relive the original horrific experience in all its rawness and as if it were happening to them now, in the present. This is why they are so disturbing. Being with a client who is having a flashback may feel like being in the same room as a child being tortured, and knowing one cannot do anything to prevent it from having happened. But the therapist needs to keep very well grounded, so that we can turn it into a healing abreaction rather than a re-traumatising reliving of the experience. An abreaction is the emotional release or discharge after recalling a painful experience that has been repressed. I may be using the terms, abreaction and flashback, almost interchangeably. A flashback as such, does not have the capacity to bring about processing of the memory experience, and is traumatic in itself, thus adding to the suffering of the victim. An abreaction, which includes the emotional reaction as well, may lead to healing and integration of the memory, but not necessarily. Clients who experience a lot of flashbacks may find it quite difficult in general to be grounded in the present, as the past experience has such a powerful pull. They may also experience other dissociative phenomena such as depersonalisation, derealisation and disorientation. In working with clients who have been severely traumatised in childhood, dealing with flashbacks in the sessions becomes an important and usually unavoidable part of the work. There needs to be a good-enough therapeutic relationship in place, before abreactive work can be successfully undertaken. Such a relationship needs to have the strength to sustain the sense of ‘safety in the present’, while the client is going through the abreaction. The focus in the early stages of therapy needs to be on stabilisation, containment, psycho-education (to help the client understand what is happening) and the developing of techniques for staying grounded in the present as much as possible (see ‘Stages of Therapy’ article by Mike Fisher). In therapy, an abreactive experience may occur spontaneously, in response to an accidental trigger, in which case, it needs to be contained as carefully as possible, perhaps using some of the methods described below, or may be carefully prepared for. More commonly, in my experience an abreaction is preceded by a period of mounting internal pressure and conflict lasting for days or even weeks before the abreactive resolution itself. It is as if a part of the self who has been holding unprocessed traumatic material from the time it happened, gets closer to the surface, with an urgent need to release the experience. The internal pressure is due to an increasingly dangerous-feeling power struggle between this part and other parts who have been maintaining the dissociation. When a client has had some beneficial resolution in working with memories, and the denying or hostile parts have found new roles (or at least are less powerful in the system), then the client may collaborate with the therapist in working with whatever disturbing material is close to the surface, in a more planned way. Parts that deny or ‘maintain the dissociation’ These parts are often also stuck in the past and aware only of the sense of danger, lack of power, isolation and helplessness experienced at the time of the trauma. They would feel very threatened by the emergence of the traumatised part, as if still having the same need to safeguard the rest of the self by keeping the experience both out of consciousness but also, unknown to external others. They had a very important protective role in maintaining the dissociation. Another denying part would be likely to have identified with the perpetrators’ attitudes towards the traumatised part of the self, and then used these attitudes (threats, tone of voice, perceived power, etc) as tools to keep the repression in place. Such a part often feels a sense of guilt towards the other parts, and a fear of rejection by them, when the memory of the traumatic experience does break through. The first task may well be to communicate with these parts until they develop enough trust in the therapist, to, at least loosen their grip somewhat on the dissociated material. The denying parts need to be: valued for the vital nature of their role in helping the whole of the rest of the person to have survived by keeping this material hidden away, relieved of the intolerable burden of having been on guard duty for all those years, brought into the safety of the present, understood, validated and, when ready, to negotiate a new role. The Abreaction Then, as the balance of pressures gradually changes, the previously hidden traumatic experience is allowed to surface in the form of an abreaction in the therapy situation. Because the unprocessed flashback material is frozen in time, the client will be drawn back into that time, as if she were still right there. Part of the preparation needs to be developing the experience of co-consciousness, so that while experiencing the flashback, the client is also aware of the present and its safety. The main task of the therapist during an abreaction is to maintain vital contact with the present, and to hold that for the client. When an abreaction begins to unfold, the therapist may keep speaking to the client, with such messages as, ‘It’s not happening now’, ‘You’re safely here in this room with me’, ‘It’s safe to let it come through now’, ‘You will survive because you did survive then’. The therapist can let her know that as it’s not actually happening now, the experience can be interrupted, she can take a pause from it, if she feels that would be helpful. She can be asked to give a hand signal to show if she chooses to do that, and, if so, then the therapist helps her to ground herself in the present for a while until she is ready to go back into the experience (if she feels that is what she needs to do). The therapist is providing a strong sense of safety and containment in doing this, and it helps to give the client a sense of mastery over memory material. It may also be appropriate (if previously discussed and agreed with the client) to offer a hand to hold, so that there is a physical anchor to the present, as well as the sound of the therapist’s voice. In adaptive information processing theory (Shapiro 2002), the linking of the neural networks holding the traumatic material, with present healthily adapted networks is the foundation of the adaptive resolution of traumatic experiences. This is partly why an often lengthy period of preparation and stabilisation is needed before working with the traumatic material. There needs to be easier accessing of, and/or building of secure enough ego-strength and grounding in the present. The development of the relationship and the client’s ability to internalise it, is vital to such a foundation, and may sometimes take months or years before the client is ready. It is often very hard for a deeply damaged person to internalise much of the secure relationship, and it requires time, patience and commitment on both sides. I have written this article from my own experience with clients suffering from DID, but also recognising that I have learnt, consciously and unconsciously, from my clients, from others’ experiences, through reading and training. Each client is unique, and one adapts the way of working to each client. Some of what I have written above may not be relevant to the next clients I see, so I recognise, may also not be relevant to your clients, but I hope something of it may be useful. I would be very pleased to hear of others’ thoughts and experiences on handling flashbacks or abreactions, so we can learn more together. Shapiro, F (2002) EMDR as an Integrative Psychotherapy Approach: Experts of Diverse Orientations Explore the Paradigm Prism. American Psychological Association, Washington. Nel Walker [back to top...] Postal and Email Counselling Some thoughts shared from the experience of Louise Lewis who has been involved in postal and email counselling since 1988. This kind of counselling may be a very helpful starting off point or extra support for people suffering from the effects of severe trauma in childhood. Or it may be an idea that readers may want to consider developing themselves. Louise may be contacted for further information about this at postalcontinuity@hotmail.com. (Ed) General Points Postal or email counselling can be used in various ways and for different purposes. The following comments are an attempt to convey the nature of this type of work as it has developed, from our experience within the approach and framework of our organisation. Counsellors working in this way need counselling skills, flexibility and an ability to engage in 'conversation via writing', picking up and expanding on points where appropriate, and perhaps matching the person's style. They also need the ability to be working in the dark to an unusual degree. There is no average period of corresponding, and we may remain in some form of contact with clients for a number of years, receiving only an occasional update or postcard. Sometimes clients write in again if the going gets tough. Letter and tape conversations are conducted from the beginning on the basis of not referring to past correspondence, working from memory or checking back with the client regarding something previously discussed, and this seems to work well and naturally. We tell clients that letters are not kept long-term. They are shredded on a regular basis, and any tapes are cleared. Counselling is informal in nature, but is not encouraged to run its course without a critical eye from time to time. We ask if any other form of help has been tried and what approach they feel suits them, and work around that. People do a lot of the work themselves, but someone else showing interest and support can make a significant difference. In September 1999 the British Association for Counselling and Psychotherapy published a very informative booklet 'Counselling Online: Opportunities and risks in counselling clients via the Internet.' ISBN 0 946181 78 0 or see www.bac.co.uk. Points in favour Writing things down on paper can help clients consider their options better, whether or not they actually send a letter. Interaction of a generally supportive kind, can lead to correspondents establishing better boundaries for themselves. Some find it hard or impossible to talk about their problems in the early stages. Writing to someone they don't know may be easier to do. Correspondence can build up to the point where the client feels able to look for extra help locally, or for a specific form of help. Information on other resources can be provided. Some correspondents may already be in a counselling, therapy or support situation, yet find it helpful to have some other contact, especially if the therapy relationship is not working well, or is drawing to a close. The postal counsellor needs to fit around whatever else is going on for the client in terms of other therapy and the person's life and circumstances. Postal contact can be especially useful for a client living in an institution. A confidential service is offered, although clients may need to guard confidentiality at their end, if there is risk of mail being read by someone else. Time to reflect on a reply before it is sent. Correspondence can progress into talking on tape in both directions, like a delayed phone call. A personal, organisational or a forwarding address can be used. Neither the counsellor nor the client in postal or email counselling is tied to a time or place. Inexpensive to run and for clients to use. Some points to consider as possible disadvantages Misunderstandings can arise, and we ask clients to come back to us if there is anything that has been misunderstood, or they are unhappy about or wish to ask. Confidentiality may be a problem if there is a risk that correspondence may be read by someone else. A client may feel let down in some way because their expectations of us are not being met, and we ask them to read our general disclaimer about responsibility before becoming involved. Louise Lewis postalcontinuity@hotmail.com. [back to top...] Some Reflections on Containment “The behaviour is not the problem, it is the solution. So what is the problem?” (Norma Howes at the TAG conference “Dissociative identity disorder and working with survivors of trauma and ritual abuse” at Swanwick in January 2000). Norma’s statement provides a refreshing perspective indicating that survivor’s behaviour may be less abnormal than we may be used to thinking. It may well be an attempt to regulate some difficult life experiences. It may be that the difference between sanity and madness is less to do with the degree of distress experienced in one’s life and more to do with one’s capacity to express it. Only then can one start to make sense of the confusion, pain, anxiety and fear that is felt. The importance of “containment” as a means of providing a sense of safety for the client to explore feelings that may otherwise be experienced as overwhelming and confusing cannot be under-estimated. Containment is often about “holding” the alarm, confusion and pain of unfamiliar or overwhelming feelings. Containment may be described as the capacity of one person to stay with and psychologically and emotionally hold the distress of another person in such a way as to allow it to be coped with. In the words of Patrick Casement in his chapter on key ‘dynamics of containment’ “… what is needed is a form of holding, such as a mother gives to her distressed child. There are various ways in which one adult can offer to another this holding (or containment). And it can be crucial for a patient to be thus held in order to recover, or to discover maybe for the first time, a capacity for managing life and life’s difficulties without continued avoidance or suppression.” (1985) The counsellor will need to manage his or her own sense of uncertainty and confusion in order to be effective in assisting the client in managing their own feelings. If the counsellor can provide the confidence and presence that enable a client to believe that his or her difficult feelings can be managed, explored and understood then the client is less likely to resort to unsatisfactory coping mechanisms or to escape into a delusional private world. In order for containment to be effective the counsellor will need to have some sound models of human functioning and an understanding of the developmental process. Without these they will risk being drawn into the client’s state of “alarm and confusion” and absorbing the client’s sense of feeling overwhelmed. The models can provide the map and compass to help work out where in the process the client is, and also where he or she needs to go in their journey of recovery. Models can provide the framework within which you both exist and can also provide the assurance that even if things don’t seem very clear, it does not mean he or she cannot find a way through. One thing more alarming for the client than his or her own feelings, is other people’s fear of the client’s feelings. A counsellor’s capacity to hold the uncertainty of a client’s situation and his or her “difficult” feelings will be central to sound containment within which the client is enabled to make progress. Good supervision is essential for the counsellor committed to providing effective containment for their clients, and, where necessary, a counsellor’s own therapy. Another very valuable resource is that of keeping up with the rapidly changing developments in the field of early life trauma studies. These factors together with listening to the client may provide the essential ingredients for containment. References: Casement, P (1985) On Learning from the Patient Routledge. Casement, P (1990) Further Learning from the Patient Routledge. Wosket, V (1999) The Therapeutic use of Self – Counselling Practice, Research and Supervision. Routledge. Mike Fisher [back to top...] Affect Regulation Skills contributed by Nel Walker (Based on the work of John Omaha - 2004) Nel will be presenting a brief experiential workshop based on this material at the TAG Conference in April. No classes or tutorials are ever offered for handling emotions, yet it is something that is absolutely vital to our well being; our health, our sense of self and all our relationships depend upon it. We suffer if others close to us have problems themselves with it. Deficit in the area of affect/emotion regulation is a large factor in many, if not most, relationship problems, in violent behaviour towards self and others, phobias, addictive behaviour and depression. Affect/emotion regulation skills normally develop naturally within a good enough attachment relationship with the primary caregiver in the child’s earliest two to three years of life, and as healthy brain development unfolds. Other factors are: genetics (inheritance sets the thresholds for affects) and the child’s socio-emotional history from 3-4 years until adolescence. The person fortunate enough to have developed affect regulation skills in good enough measure is not usually aware of this valuable skill but often puzzled by others who have not been so fortunate. The skills usually operate unconsciously. Whilst it is recognised that a good psychotherapeutic relationship provides for the unconscious transmission of self-regulation which can lead to some extent to the remediation of a client’s early deficits, Omaha proposes that they may be transmitted in psychotherapy in a more active way, and that the means to do this early in the therapy relationship also gives an opportunity for the client to experience flexibility and attunement from the therapist, leading to a greater sense of safety and security. Omaha also asserts that we have a responsibility to teach or transmit these skills as they are a vital part of preparing a client for working with traumatic material. He emphasises the importance of this by pointing out the link with the child’s developing self-structure: ‘Affect regulation and structuring of the self are conjoint processes which cannot be separated.’ Clearly, any person suffering from a dissociative disorder (and also most with any significant psychopathology and a large proportion of the general population too) will have problems with regard to affect/emotion regulation. Any positive learning of affect regulation skills in treatment will contribute markedly to repairing deficits in the client’s self-structure and also helps to widen the window of tolerance for processing traumatic material. Below are definitions of the words ‘affect’ and ‘emotion’ as used by Omaha, and as originally developed by Tomkins (1962 and 1963) and Nathanson (1992). ‘Affects are the genetically hard-wired physiological building blocks from which feeling, emotion and mood are constructed.’ There are ‘nine basic affects: excitement, joy, startle, fear, anger, anguish, shame, disgust and dissmell’’ [dissmell: an affect which forms a foundation for the emotions ofdisgust in all its wider ramifications, such as shame, self-loathing. Ed.] (Nathanson 1992). ‘Emotions are affects modified by experience. In emotion, affects are assembled with images, memories, cognitions, introjects, and other affects.’ ‘As Nathanson (1992) wrote, “affect is biology, emotion is biography” (p.50).’ People may be overwhelmed by specific emotions by emotions in general, and also by the fear of experiencing any emotion at all. Some may experience panic attacks, or angry outbursts which they feel are outside of their control, or else others may be very flat or numb emotionally, or the emotion becomes displaced, projected or maybe being expressed somatically or in self-harm. Some clients, especially those with dissociative disorders may alternate from one state to another. In some cases emotion regulation skills develop adequately in childhood, but subsequent overwhelming traumas seriously compromise this skill. Affect regulation is the capacity for affects and emotions to be actively and appropriately available, for one to feel safe and grounded whilst feeling the emotion, for the emotion to be experienced at a level that is appropriate to the circumstances, and under the control of cognitive evaluation of the situation, but, more than that, affect regulation provides a basis for developing a secure self-structure. Omaha, drawing on the recent work of many well-known authors and researchers in the field, presents a way of working with clients, which he calls Affect Management Skills Training (AMST), which can be used with clients to regulate affects. I have been using his model with a majority of my clients in one form or another for about five years, especially with victims of trauma. The client usually finds that he/she can use the skills outside of sessions, thereby reinforcing them and gradually developing a sense of mastery, leading to the unconscious operation of the skills as new neural pathways are developed which seem to fill the templates in the brain for the establishment of this natural ability. In AMST the therapist communicates with the client’s right brain through the use of imagery and felt body sense, and links these with cognitions. There are several components involved. The first skill to be transmitted is the ability to confine disturbing material in an image of a container. The second is the building in of a bodily-experienced locus of safety or comfort. Then follow a series of skills for regulating specific affects. The client is helped to choose a target affect at a low level of intensity, on which to focus, then learns skills for recognising, noticing and tolerating the affect, whilst experiencing being grounded and in the present, and then the ability to down-modulate the affect to a chosen and ecologically appropriate level. Usually a client is quite surprised at the difference, and is enthused to practice these steps on their own until they become automatic and body-led. In most cases this leads to the ability to regulate emotions without being cognitively aware of it. Emotion management increases the integrative capacity and level of psychological tension required for processing trauma, so needs to be in place before any uncovering or treating of traumatic experiences is attempted. John Omaha originally published a paper on AMST in 2001 in the arena of trauma therapy, specifically EMDR, and has continued to develop his thinking in conjunction with other therapists as they have discussed to queries and problematic case studies on his internet discussion forum and also through the workshops he presents. He is experienced in working with clients with DID and although AMST has built-in flexibility and responsiveness to the individual client’s needs, suggests further modifications in using this way of working with people with DID. Nel Walker References: Nathanson D L (1992). Shame and Pride: Affect, sex and the birth of the self. New York: Norton. Omaha J (2004). Psychotherapeutic Interventions for Emotion Regulation: EMDR and bilateral stimulation for affect management. New York: Norton. Tomkins S S. (1962&1963) Affect / imagery /consciousness. Vols. 1&2. New York: Springer [back to top...] The Impact of Attachment Trauma on the Helper Understanding the impact of childhood trauma on attachment and the regulation of emotional arousal informs the process of healing (e.g. Solomon and Siegel, 2003). It is useful to apply this expanding area of knowledge to the impact of working with attachment trauma on the helper's own attachment system and capacity for emotional regulation. 'Helper' is used here as an umbrella term for a variety of roles, both professional and voluntary. To provide a secure enough base for the survivor's healing journey, the helper needs to be able to regulate their own emotional state and to have a secure enough base of their own. Studies (e.g. Dozier et al., 1994) have highlighted how different care giving responses elicited in helpers according to their attachment style effect the therapeutic process. For example, regardless of client need, helpers with a preoccupied style may intervene more while those who are dismissive may tend not to. As helpers, we would probably all like to think of ourselves as secure enough to respond appropriately to the client's attachment needs whatever our own attachment style. However, I suspect that anyone who stays the course as a companion on the survivor's journey will find it hard, at least at some point, to avoid becoming over-aroused in attachment terms. It is both normal and inevitable that the helper's attachment system will be activated by intense insecure ambivalent, avoidant or disorganised care seeking by survivors whose attachment needs have been exploited and betrayed by their abusers. For example, hearing the experiences of a survivor of satanic ritual abuse can lead to anxious, over-involved care giving or to avoidance and disengagement. Persistent exposure to emotional deregulation in the absence of adequate care, leads to burnout and secondary traumatisation. This causes not only personal and professional distress, but also restricts the capacity for reflection and exploration so essential to helping work. There are several routes by which we can maintain and restore our emotional equilibrium and with it, our reflective and exploratory capacities. Van der Volk (Counselling and Psychotherapy Journal, May 2004, 10-13) speaks of the particular need of trauma workers for self-soothing, restorative activities such as meditation and yoga. Such physical, reflective and spiritual activities reduce stress, the volume of stress hormones in our brains and help us to hold on to a sense of meaning. As well as self-care, we also need good enough care giving. This might come from someone perceived as older or wiser but can be from a variety of sources as long as it is sufficiently reliable and companionable. For example, on exploring my experience as a professional caregiver in a threatening and deregulating environment, I identified the absence of supportive and companionable peers as a major source of distress and the support of a few key people as a key component of recovery (Richardson and Bacon, 2001). Those survivors, who are severely symptomatic, and especially isolated struggling to be self-reliant or stigmatised by other sources of help are a particular challenge to our capacity for self-regulation. How do we respond without either abandoning the survivor or becoming the sole, overburdened caregiver? Thinking creatively and forming 'virtual' teams (e.g. with referrers, other practitioners involved with the survivor) or offering packages of assessment and consultation might be more constructive than saying ‘no’ or more realistic than asking the survivor to find a support system as a precondition for counselling. Identifying the challenge of emotional regulation may be a helpful way to view colleagues who struggle with their boundaries or who fail to engage in difficult terrain. We can also make decisions on training, conferences and other professional activities in the light of how far they are likely to be stimulating and supportive without being too deregulating. If we can stay in touch with the complex drama going on in our own brains then we will be better equipped to attune to the narrative of trauma being played out in the lives and minds of those who seek our help. Sue Richardson References: Dozier, M, Cue, K. L and Barnett, l. (1994) Clinicians as Caregivers: Role of Attachment Organisation in Treatment. Journal of Counselling and Clinical Psychology, 62, 4, 793-800. Richardson, S. & Bacon, H. Piecing the Fragments Together. In: Richardson, S. & Bacon, H. (Eds.) Creative Responses to Child Sexual Abuse: Challenges and Dilemmas. London: Jessica Kingsley. Solomon, M. F. and Siegel, D.J. (2003) Healing Trauma: Attachment, mind, body and brain. London: Norton [back to top...] Are you a Brain Organiser? According to recent neurobiological findings, if you are a counsellor or psychotherapist, then you are a Brain Organiser, as you are involved in a process that changes neural organisation, structure and functioning. Neuroscience is providing us with an increasing understanding of what happens in the brain during psychotherapy, and strongly validates it. The therapeutic relationship, whether one thinks about it or not, has always had the effect of changing the client's neural organisation. The art of psychotherapy, which has evolved quite separately from scientific knowledge, seems to be doing mostly the 'right thing', according to brain scientists, who's work is bringing knowledge and understanding of what happens at the neural and physiological levels in the therapeutic relationship. These affirmations of what psychotherapists and counsellors have already been doing, largely intuitively, may have many benefits including the following: A greater feeling of confidence in what we are doing by providing a safe, empathic, attuned and containing relationship, thus helping one to hold steady and stay grounded even when times are challenging beyond the norm. One would be working from a firmer foundation from which the thinking and choice of intervention is likely to be more helpful. For instance, if we understand how the interaction with the client can have a regulatory effect on the client's affect system then we will be able to refine what we are doing and so do it better. We will be more able to help clients themselves to understand, where appropriate, what is happening in their own brain, mind and body when, for instance, he or she is triggered and has a panic reaction, or what is happening when experiencing disturbing ambivalence in the relationship with the therapist. Insights such as these can help to empower the client, to normalise their symptoms and help them to be more of a curious observer of those symptoms rather than being caught up in and taken over by them. When clients begin to understand that their problems and symptoms in the present are based on normal and recognised responses and adaptations to their abnormal early experiences they are likely to feel more self-accepting and hopeful of a way forward. New understanding of how the mind-body system works is opening up new ways of working which can be even more effective and focused without minimising what we have always known about the importance of the relationship. There is a buzz of excitement caused by the growing synthesis between the art and the science of psychotherapy, as it appears to be offering potential for greater strides forward in working with very damaged people. There is an energising and empowering bridging of the gap between the clinical field of mental health and the independent field of neuroscience. Margaret Wilkinson, a Jungian analyst and author, presents counsellors and therapists with a challenge. She writes: "Sound therapy requires an understanding of mind, brain and body. Now such knowledge is available, nothing less will do." (Wilkinson 2006) She also asserts that knowledge of current neuroscience can enable clinicians to, "come to a clearer understanding of why they do what they do, especially in relation to the unconscious, empathic, dynamic aspects of work in the transference and counter transference". Here are some quotes I came across recently describing psychotherapy in terms of this new conceptual framework: "Psychotherapy is currently conceptualised as being directed towards the mobilisation of fundamental modes of development and the completion of interrupted developmental processes." (Schore, 2006 Workshop) Cozolino proposes that people who seek psychotherapy have, at the basis of their needs, the problem of neural networks, which have been underdeveloped, unregulated or un-integrated. "At the heart of psychotherapy is an understanding of the interwoven forces of nature and nurture, what goes right and wrong in their developmental unfolding and how to reinstate healthy neural functioning. When psychotherapy results in symptom reduction or experiential change, the brain has, in some way, been altered." (Kandel 98, from Cozolino 2002) "Psychotherapy is an attachment relationship capable of regulating neurophysiology and altering underlying neural structure." (Amini et al, Psychiatry 1996) This is what we are doing! Almost all of the above, applied to psychotherapy, is parallel with the relationship between mother and baby and the shaping of the developing brain in that interaction, for better or worse. But a client is not a baby! Of course, we are not just dealing with the problem of 'underdeveloped, unregulated or unintegrated' neural networks. Our severely damaged clients' brains have been badly messed up, by the effects of neglect, misattunements, trauma, shaming, lack of safe containment and so on. In the developing brains quest to bring order, meaning and adaptation out of harmful and inadequate experiences, development will naturally have taken place, but dysfunctionally, affect would be dysregulated and many neural networks would remain unintegrated and prevented from integrating by conditioned fear. The inadequate and traumatising raw materials of experience offered by such toxic parenting and/or other damaging cultural forces, have led to the many problems and symptoms we see in clients with dissociative identity disorder or complex posttraumatic stress disorder, symptoms that affect every level of functioning of the brain, mind and body. The science of psychotherapy is holistic Knowledge from the field of science underlines the interconnectedness of body, brain and mind, and the significance of involving all three brain levels (cognitive, limbic and sensorimotor), and the body in psychotherapy. It has also helped to shift the emphasis of where we need to work towards the sensorimotor and limbic structures of the brain, as being key in understanding what is happening, and away from the previously assumed greater significance of the cognitive areas, although all areas are important and interrelated. The challenge of neuroscience Traditional good psychotherapy models that are based on a safe, reliable, attuned, and contained relationship have been validated by neuroscience and the field is also being offered the tools for developing more effective psychotherapy. Could psychotherapists improve on the effectiveness of neural reorganisation by providing more clear raw materials, especially in some areas of experience such as affect regulation or the sense of continuity through time, in order to help the client towards a clearer reorganisation of their internal map or sense of self? Some of the most exciting developments that I have come across recently that seem to offer such ways forward, which are practical as well as grounded in current neuroscience, are in the following areas: Sensorimotor Psychotherapy - developed by Pat Ogden and for which there are training course now running in the UK. More information about the concepts can be found at: www.sensorimotorpsychotherapy.com Structural Dissociation of the Personality as a result of Trauma - no specific trainings available in the UK at present, but the book 'The Haunted Self', by Nijenhuis, Steele and van der Hart, has been published by Norton and provides some very helpful knowledge and tools to all those who work with traumatised people. Emotion Regulation - the best book I have come across in this field, and one that is based on all three levels of brain functioning, is John Omaha's 'Psychotherapeutic Interventions for Emotion Regulation' (2004). Norton. Lifespan Integration - developed by Peggy Pace in the USA. Training in UK beginning in 2007. Her book is available from the web site: www.lifespanintegration.com There are many others too who are developing ways forward in psychotherapy and counselling based on the new synthesis between the art and the science of psychotherapy. It may be useful to share more knowledge of different developments with each other. Perhaps you could add to this list, keeping us in touch with ways in which an increasing synthesis with the world of science is affecting the theory and practice in your areas of work and experiences. Wilkinson suggests that the integration of neuro-scientific data and psychodynamic models will lead to a resurgence of imaginative and thoughtful clinical work. Allan Schore adds "What better outcome of a paradigm shift than that?" (Wilkinson 2006, Foreword) References Amini et al (1996) 'Affect, attachment, memory: contributions towards psychobiologic integration' Psychiatry, 59, 213-239 Cozolino L (2002) 'The Neuroscience of Psychotherapy: Building and rebuilding the human brain.' Norton, New York. Wilkinson M (2006) 'Coming into Mind: The mind-brain relationship: a Jungian clinical perspective. Routledge, London. Schore A (2006 Workshop) 'The Art and the Science of Psychotherapy.' Nel Walker 2006 Clinical Psychologist in Private Practice [back to top...] An Integrated Overview of Functioning In order to best appreciate and understand the effects of trauma on people it is crucial to recognise the role played by different elements of our being and especially the relationship between them. The key elements could be summarised as follows: The role of the brain as the communication and control centre of the body. The complex structure of the brain controls organs and glands, holds our capacity to function, think, move, feel, react and undertake a myriad of tasks and activities. The brain is instrumental in the formation of memory, speech and language and in organising all the activities required for our survival. In crisis situations the more established (and more primitive) parts of the brain takeover and override the later (but more developed) parts of the brain. In trauma these can become the default positions. The nervous system is the communication network in the body. It has some pre-programmed (autonomic) parts of the system that are automatically triggered into action at the signals of danger. The neurotransmission system is a range of both simple and complex chemical messages that move between the brain, nervous system and body. Some of these neurotransmitters, steroids, hormones and peptides are responsible for very powerful reactions within us. Whilst there is often a feedback loop to stop us being flooded with unnecessary amounts of these chemicals these do not always work, especially if we have overwhelming experiences like trauma. The body is the container within which all our living activity takes place. It is not only made up of muscle and bone but also a range of life supporting organs and is covered with skin. The body plays a key role in registering and recording our experiences and in holding cellular memories within the millions of nerve cells that are present in every part of it. The body is therefore very significant in registering our experiences of trauma, containing the unresolved effects it has on us and in providing the sensations and movements that enable us to resolve and recover from traumatic stress. Our thoughts, consciousness, spirit and being all have a significant part to play in resourcing, resolving and recovering from trauma. The world of therapy is still straddled between the dualistic thinking that dominated western approaches to understanding since the writings of Descartes and to incorporating the rapidly escalating insights and knowledge made available through brain imaging and neurobiology. Dualism is still widely reflected in the many "singular" modalities within the therapeutic world that put an emphasis upon "Cognition", "Behaviour" or "Emotions" as the prime focuses for change, with little recognition of the role of the "body" in the process or any regard to the role of the "spirit". It is without a doubt that nearly all modalities have something to offer the process of recovery, but until more holistic overviews are achieved, and more integrated approaches adopted, the potential of full recovery may not be realised or progress may be slower than necessary. There might be even greater danger in some Christian inspired counselling approaches that put a very strong emphasis upon Descartes' belief in the dominance of "thought, reason and the will" as that which makes us human, at the cost of understanding "what" may be happening for some people. This may well account for the number of survivors who emerge from those religious settings that have sought to help them, only to experience re-traumatisation. It is important to realise that it is not the intentions that were wrong only the understanding and interpretation of what was happening that was in error. Hopefully with greater and increased awareness in both clinical and pastoral settings distress and re-traumatisation will be less common. We all need to have a commitment to continued professional development (CPD), have an open and enquiring mind, and to realise that what we understand or believe now may be different in a year or two's time as greater understanding emerges with new insights and knowledge. Mike Fisher, 2006 [back to top...] States of Consciousness Our states of consciousness are influenced by our brainwave patterns and by our left and right brain hemisphere activity, amongst other things. Brainwave wave bands can be understood as: - Gamma Waves (over 30 Hz frequency) - learning, memory, perception - Beta waves (12 to 30 Hz frequency) - anxious thinking, focused activity, REM sleep - Alpha waves (7 to 12 Hz frequency) - awake but relaxed - Theta waves (3 to 7 Hz frequency) - drowsiness, early sleep, trance states - Delta waves (1 to 3 Hz frequency) - deep sleep - Slow waves (below 1 Hz frequency) - non-activity or preparing to move As part of a regular cycle we both change our brain wave pattern and move from left brain cognitive thinking to right brain processing every hour and a half for about twenty minutes. This is usually when we become restless, distracted, and fidgety and can end up daydreaming. This may explain why meetings that run longer than an hour and a half without a break are less productive. A similar process goes on in our REM (rapid eye movement) sleep in a more extensive way. This is one of the ways we process the extensive amount of data, information, perceptions and thoughts that we take in. It is also why we so often seem to have solutions, creative thoughts and enhanced learning when we have had a break or a good nights sleep. The right hemisphere of the brain is much more associated with creative and abstract thoughts and activities and is much more open to suggestive input. A similar process happens when we become engaged and focused on an activity that draws on this side of the brains activities, such as a hobby or pastime, watching a film or reading a book. The consequences are that afterwards we feel more satisfied, relaxed, fulfilled and more energised to take on life's demands. This is also why regular rest and play are essential for a sense of well being and effective functioning. Altered states of consciousness can be described as 'dissociated' or 'semi-hypnotic' states, where our consciousness excludes awareness of other 'outside' information, stimuli or activity. This is where we experience being in another world of our own thoughts or experiences. Our bodies and brains move through different levels of brainwave activity through the day and night depending on what we are doing. Survivors of trauma experience pathological dissociation, as a result of the trauma, and may suffer from structural dissociation of the personality. The dissociation becomes a mechanism for coping with the unresolved intrusions and avoidance responses that occur as a result of being overwhelmed by a traumatic event. Activities or events that lead to the defensive barriers or gates of dissociated states being bypassed can lead to the survivor experiencing emotional flooding by the traumatic experiences and going into states of hyper-arousal or hypo-arousal. Other triggers such as music, visual imagery, lying down horizontally, prayer ministry, meditation, massage and touch can all be activities that might lead to the breakdown of these defenses. This can account for traumatised individuals experiencing mood swings, emotional states, blanking out, "switching" or responding in a perplexing, uncharacteristic or incongruent way. It may also be the reason why some survivors find settings such as church, which would normally be a place of comfort for many people, difficult or distressing. If this happens the survivor needs to be helped to be grounded and consciously aware of their surroundings. It is important that they are enabled to feel physically safe and are brought back into their "window of tolerance" from states of hyper-arousal or hypo-arousal. It is also important that anyone for whom this happens is not made to feel more guilty or ashamed than they already do. Only then will they be able to regain their equilibrium and an increasing capacity to cope with life's demands. Mike Fisher, 2006 [back to top...]
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Working Approaches

Working with survivors of ritual abuse

A Three Phase Approach to Recovery

Some Thoughts on Handling Flashbacks and Abreactions in Therapy

Some Reflections on Containment

The Impact of Attachment Trauma on the Helper

An Integrated Overview of Functioning

Helping to change the world

Over the last 20 to 30 years our society and our culture has evolved through considerable and probably unprecedented change. Nowhere is change more evident than in the fields of micro-technology and tele-communications, with all its implications and impact on our daily lives whether in daily living, leisure or work.

There have of course been many other changes, although not all of them quite so obvious. Amongst the changes that have taken place are the increased understanding of our own human functioning and of our needs, both as individuals and as social systems in society.One trend in the past thirty years has been the readiness of people to talk about difficulties in their own life, which has lead to an increase in counselling and other forms of therapeutic help. This trend has made it more possible for individuals who have suffered from more extreme forms of early life trauma and abuse to disclose to others and to also seek help.

Ironically, contraction in public services, with limited public health provision and absence of specialist provision has lead many people to seek help from voluntary organisations, churches, independent counsellors or voluntary counselling agencies. Conditions such as Post Traumatic Stress Disorder, Unresolved Insecure Attachment Difficulties, Dissociative Disorders and all the associated relational and behavioural problems may well be amongst the conditions presented to counsellors and carers by some people seeking help or support.

There is now real necessity for counsellors, carers and churches to be able to recognise and understand these conditions, if the help being offered is going to be effective and not aggravate the person’s condition with mistreatment or even abuse. This situation is particularly difficult for a survivor of ritual abuse because of the widespread diffidence that exists in the public’s mind about whether ritual abuse actually exists. Denial, disbelief and misdiagnosis are tragically common place experiences for survivors of such childhood atrocities. Despite the increasing number of press reports of varies forms of ritual abuse, and the now quite large number of people in therapy who describe this as part of their background, officially it is still deemed not to exist. This not only creates phenomenal difficulties for survivors but also leaves counsellors, carers and other professionals extremely isolated in their task of helping client through to recovery.

Four years ago the ACC commissioned a working party under the chairmanship of Revd David Woodhouse to consider the whole area of childhood ritual abuse, and to come up with some guidelines for the training committee on the sort of training that would be most helpful to counsellors and carers who are working with survivors.

The working party decided to make the focus of its report ”Working with Dissociative Disorders” as many survivor of childhood abuse, and all survivors of ritual abuse, would be likely to be suffering from Dissociative Disorders including some who will suffer from Dissociative Identity Disorder (previously known as Multiple Personality Disorder). Other parallel conditions that survivors will experience will include Post-Traumatic Stress Disorder and Insecure Attachment.

The working Group decided to also form the “Trauma and Abuse Interest Group” (TAG) as an affiliated group within ACC, as so many counsellors and carers had asked for ongoing information, training, networking and support. TAG now produces a twice-yearly newsletter with articles and information, a contact list, training days and workshops and will be putting a course on at the next ACC National conference in 2003. Subscription for TAG is £10 a year via the contact address at the end of this article.

The response of the ACC board to the report has been very encouraging, acknowledging that counsellors need to know about Dissociative Disorders, and should have access to training, support and appropriate supervision. It is very encouraging that the Christian counsellors’ national association is both recognising this area of work and seeking to appropriately support counsellors working with survivors of extreme childhood abuse. More importantly it gives a message to survivors that they are believed, cared about and that hope does exist for their recovery. It also means that counsellors need not struggle in isolation, unsupported by their own national association.

Working with survivors of early life trauma and ritual abuse is a complex area of work, which is long term, intense and painful for both clients and counsellor. However with many advances in bio-neurology, clinical understanding is changing rapidly. It is important as carers and counsellors that we can keep abreast of developments and can keep a balance between demonstrating the unconditional love of Christ in all situations and the professional good practice needed in working in this area.

The harsh reality is that many survivors cannot find or afford counselling or professional help or get the informal support needed to make the journey of recovery. Of those, who do find a counsellor, some have to face the fact that counselling gets terminated as soon as ritual abuse is mentioned. Although there are many counsellors effectively helping survivors, there are also counsellors who are struggling or whose supervisors do not have the experience in this field of work. For those survivors who turn to the church, it is not easy to speak about their experiences, many still find themselves misunderstood, or worst still, subjected to oppressive teaching or even abusive deliverance for what is a clinical condition.

There is a major task to undertake of awareness raising in a disbelieving and punitive world. The medical establishment has yet to fully take on board the clinical implications of Dissociative Disorders and the effects of disrupted attachment. The legal system is unable to accommodate the needs of abused, traumatised and dissociative clients and the Parliamentary system has not once mentioned ritual abuse in either House in the last five years.

It is against this background that the very positive response from the Board of the ACC may enable and contribute to an important and much needed public understanding. This includes ensuring that counsellors are equipped and supported in helping survivors to both recover and have a voice, that understanding is increased and that information is shared. ACC can also support counsellors to help churches, voluntary organisations and Health and Social Service agencies to more effectively play their part in survivors’ recovery. In our own small way we can help to change the world.

Mike Fisher - Chair of TAG

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Working with survivors of ritual abuse

Working with Clients who are Survivors of early life Trauma, Sexual and Ritual Abuse

One of the things that counsellors ask for, from time to time, are guidelines for working with survivors of ritual and extreme early life abuse. Whilst it is important to be careful about over generalising, the following may be helpful pointers in this area of work. There are likely to be three parallel processes of on going work. These are unresolved insecure attachment, post traumatic stress disorder and dissociative disorders (possibly including Dissociative Identity Disorder, referred to as DID) as well as possible co-morbidity with other conditions.

The first and foremost thing to appreciate is that recovery from early life trauma and abuse is going to be long term, unlike many conditions that present themselves in the counselling room. It may take many years of regular, and often intense, work to see someone through to recovery. Preparedness from early on to work with someone over a number of years, rather than weeks will be important.

The second is that the therapeutic relationship is always important in counselling. It will be even more important when counselling someone who has experienced early life trauma and abuse. It will take time for trust to build up, to the point that deep and effective work can be undertaken. The power of a reliable, consistent, dependable and accepting relationship cannot be underestimated. It will be the vehicle by which the trauma, pain, guilt, shame, fear and anxiety will be processed and resolved.

The third is that counsellors will need to develop good “containment” skills. Working with someone who has been through ritual abuse or extreme early life trauma can be experienced as a bit of a roller coaster. The counsellor will, also therefore experience the confusion and dissociation that the client experiences,, and a capacity to stay with the uncertainty will be needed. Most survivors will also have an insecure disorganised attachment pattern, in which they will be experienced as being very ambivalent in their relationship with the counsellor, (or at times avoidant) and, in the “middle phase” of the work extremely dependent. Again it is important for the counsellor not to get fazed by this, but have the capacity to stay with the client as they try to work through their attachment issues. It will be alarming for the client as they risk, possibly for the first time, allowing attachment to take place. It will also be alarming for the counsellor if they have a fear of dependency, or equally unhelpful, if they have a need to rescue.

Without a safe, close, accepting relationship it’s unlikely that the client can risk the journey of recovery. If not they will have no choice but to maintain the dissociative defences that are needed to keep such overwhelming pain sufficiently at bay to cope with life’s demands. They will have a highly developed level of hypo-vigilance and of will have learned that being compliant was necessary for their survival. Without an adequate level of effective support the opportunity to address the extent of the trauma and disrupted attachment experience will not occur. In the words of Valerie Sinason, “It’s the relationship that gets individuals through to recovery, not a particular therapeutic modality.”

Most counsellors and carers, who work with survivors, would probably agree, that the best source of understanding comes from the person themselves, who has survived the abuse and trauma. I believe, as a therapist, my role is to accompany them on their journey of recovery. Far from having any expert contribution to give them on their journey, I have found that they truly are architects of their own recovery, and indeed they have taught me a lot in the process, including about myself.

Perhaps above all else the power of listening in a very attentive and attuned way is the greatest skill a counsellor can bring to someone’s journey. This is not to dismiss the wide body of understanding, or the range of skills and techniques that can help, but without effective listening such knowledge will be ineffective.

A particular challenge that will come to counsellors in this field of work will be the fact that the client will be able to “read” the counsellor more easily than the counsellor may be able to read the client. For many survivors their very life depended upon developing very highly attuned insights as to what was going to happen next. Because of this highly developed skill, they will pick up the least little inconsistency or incongruence in the counsellor. They will be aware of the counsellors vulnerability and be able to register any defensiveness in the counsellor, all of which will be an obstacle to them feeling safe enough to risk exposing their pain.

This does not mean that survivors are especially difficult to work with, indeed they are often highly rewarding people to work with. It does mean however that counsellors do need to attend to their own “needs” both in supervision and in personal therapy, if they want to avoid such obstacles occurring in the work. It is unfortunately not unheard of to find counsellors who will blame or scapegoat clients who become resistant because they are feeling unsafe in the therapeutic relationship. An awareness of what is happening in the therapeutic relationship will be as important as addressing the ongoing trauma. Self-awareness and personal insight will therefore need to be worked on and maintained, in order to maintain optimal effectiveness. This may be one reason why recovered survivors make good therapists.

Another factor that makes this area of work somewhat different is that a fifty minute or one hour appointment once a week is not on its own usually sufficient to keep the client sufficiently stable particularly in the middle phase of recovery. Many clients find they need either longer sessions of one and a half or two hours or more frequent sessions of two or in some cases even three a week.

For clients who suffer from Dissociative Identity Disorder, their personality will have been fragmented into a number of parts, known as Alters, as a result of the severity of the early life trauma. This was formally known as multiple personality disorder.

This will particully be the case if the client is suffering from Dissociative Identity Disorder especially if there are a great many Alter parts. There are two reasons for this, the first is that there would not be sufficient time to help the “internal system” process sufficiently the current trauma and at the same time give attention to the therapeutic relationship as well as develop internal mechanisms for coping. The second is that the “child” parts will need regularity and frequency to sufficiently attach. Many survivors may find the duration of a week, and certainly a fortnight’s gap too much to cope with in managing their daily life when traumatic memories are emerging.

The consequences of insufficient support are that they may resort to less satisfactory coping mechanisms or move in and out of chaos. This is why many survivors of more extreme trauma or ritual abuse and most clients with DID often seek regular telephone or other forms of contact between sessions. If this is going to be necessary, it is much better to plan this in, when it is needed, as part of a negotiated agreement than to leave it too open and loose, as the client will be less sure of where they stand and of what support is available.

Boundaries will be an important part of the security for the client and these should be clear, but not overly rigid, as the client’s stability will fluctuate from time to time, and some changes in arrangements may be required. This will need to depend on both the client’s need and what the counsellor feels they can realistically provide.

Perhaps the last area to mention is coping with traumatic disclosures. This will constitute the other main challenge for counsellors, particularly if their client is a survivor of satanic ritual abuse. It is not uncommon for counsellors to experience vicarious trauma when working with survivors of ritual abuse. This should not constitute a problem provided that there is good supportive and “containing” supervision. It might be that the counsellor may benefit from some counselling for themselves, or would find it helpful to belong to a network such as the Trauma and Abuse Group (TAG) where they can chat to other counsellors and carers in the some field of work.

Mike Fisher Chair of TAG and Director of the Willows Christian Counselling Service

Reference “Attachment, Trauma and Multiplicity” by Valerie Sinason, 2002

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A Three Phase Approach to Recovery

One helpful model for treatment and recovery recognises three distinct stages or phases towards recovery. These can be identified as:

Stabilisation and symptom reduction
Processing traumatic memories and achieving change
Resolution, integration and recovery

However in actuality no treatment process moves through this progression in simple linear fashion. There will, at times, be considerable overlap or movement between the stages. There will also be a wide range of tasks that will need to be undertaken in the progression towards recovery.

Elements of each of the stages or phases are likely to include the following.

Stabilisation

Establishing a relationship and therapeutic alliance.
Developing trust and setting boundaries.
Assessment and mapping of the system (if DID)
Developing effective support systems.
Achieving a safe sense of physical and emotional being and environment.
Developing strategies to enhance order and routine.
Developing grounding techniques.
Seeking to recognise and manage triggers.
Develop sense of containment and coping skills.
Assist with changes in cognition and behaviour.
Promoting internal communication.
Development of safety and internal safe place.

Processing trauma and achieving change

Managing hyperarousal with cathartic expression of emerging emotions.
Reducing trauma with the recovery of specific memories.
Facilitating the association of behaviour, affect, senses and knowledge (BASK)
Reframing understanding, thoughts and feelings.
Processing traumatic disturbance to reduce avoidance and intrusion.
Developing alternatives to self-harming, phobias and destructive behaviour.
Increasing of comfort, self-nurture, reward and satisfaction.
Containing of conflicts of attachment, dependency and abandonment.
Reducing dependency on dissociation.
Managed reduction of addictive tendencies and self-harming.
Changing the patterns of fear, guilt, shame and self-blame.
Promoting internal co-operation and collaboration.
Development of crisis management skills.
Supporting verbal and creative expression.

Resolution and recovery

Achieving an increased sense of self and identity.
Increase in independence and life choices.
Achieving new, realistic life perspectives.
Association of alters, parts and functions.
Possible integration of alters.
Resolution of significant conflicts.
Expression of post-integration grief.
Strategic planning of future life.
Maintaining life functions within normal parameters.
Reduction in the expressed need of dependency on therapist.
A planned gradual reduction in therapy.

This list can only be a very basic guide to what can be a complex array of tasks that may need to be undertaken as part of the therapeutic journey. Every individual’s needs and circumstances will be different. Likewise the time involved in making the journey to recovery will vary a great deal. The only predictable factor is that it will be long term. Whilst the first phase can take a long time before survivors feel secure enough to work in depth, phase two is likely to be the longest phase of recovery. Pacing the therapeutic work and the rate that the survivor can manage is important, otherwise “flooding” and destabilisation will take place.

Some considerations for Counsellors.

Understanding different types of alter personalities and their function.
Appreciating the dynamic between alter parts.
Understand imitation DID distinguishing features.
The implication of transference and counter-transference with dissociation.
The importance of the somatic dimension of trauma & dissociation.
The relationship between trauma, insecure attachment and dissociation.
The value of creative methods and other adjunct therapies.
Using Multiaxial Assessment and Global Assessment of Functioning scale
Using the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV)
The importance of recognising patterns and trends.
The need to cope with chaos, confusion and uncertainty.
The need to deal with one’s own vicarious traumatisation.
The importance of keeping one’s own defences at a minimal level.
The value of finding the ways of working with each client that are the least traumatising.
Appreciating that this area of work is both very simple and very complex.
The necessity of supervision, support and therapy for counsellors.

Mike Fisher 2003

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Some Thoughts on Handling Flashbacks and Abreactions in Therapy

Flashbacks are the intrusive ‘reliving of trauma’ - type experiences, common to people who have experienced severe trauma. In most cases, these decrease over time as a person processes the traumatic material, but for those who develop posttraumatic stress disorder or have a dissociative disorder, these symptoms do not improve. They are like pockets of past time, intruding into consciousness, causing the person to relive the original horrific experience in all its rawness and as if it were happening to them now, in the present. This is why they are so disturbing. Being with a client who is having a flashback may feel like being in the same room as a child being tortured, and knowing one cannot do anything to prevent it from having happened. But the therapist needs to keep very well grounded, so that we can turn it into a healing abreaction rather than a re-traumatising reliving of the experience.

An abreaction is the emotional release or discharge after recalling a painful experience that has been repressed. I may be using the terms, abreaction and flashback, almost interchangeably.
A flashback as such, does not have the capacity to bring about processing of the memory experience, and is traumatic in itself, thus adding to the suffering of the victim. An abreaction, which includes the emotional reaction as well, may lead to healing and integration of the memory, but not necessarily.

Clients who experience a lot of flashbacks may find it quite difficult in general to be grounded in the present, as the past experience has such a powerful pull. They may also experience other dissociative phenomena such as depersonalisation, derealisation and disorientation.

In working with clients who have been severely traumatised in childhood, dealing with flashbacks in the sessions becomes an important and usually unavoidable part of the work. There needs to be a good-enough therapeutic relationship in place, before abreactive work can be successfully undertaken. Such a relationship needs to have the strength to sustain the sense of ‘safety in the present’, while the client is going through the abreaction.

The focus in the early stages of therapy needs to be on stabilisation, containment, psycho-education (to help the client understand what is happening) and the developing of techniques for staying grounded in the present as much as possible (see ‘Stages of Therapy’ article by Mike Fisher).

In therapy, an abreactive experience may occur spontaneously, in response to an accidental trigger, in which case, it needs to be contained as carefully as possible, perhaps using some of the methods described below, or may be carefully prepared for.

More commonly, in my experience an abreaction is preceded by a period of mounting internal pressure and conflict lasting for days or even weeks before the abreactive resolution itself. It is as if a part of the self who has been holding unprocessed traumatic material from the time it happened, gets closer to the surface, with an urgent need to release the experience. The internal pressure is due to an increasingly dangerous-feeling power struggle between this part and other parts who have been maintaining the dissociation.

When a client has had some beneficial resolution in working with memories, and the denying or hostile parts have found new roles (or at least are less powerful in the system), then the client may collaborate with the therapist in working with whatever disturbing material is close to the surface, in a more planned way.

Parts that deny or ‘maintain the dissociation’

These parts are often also stuck in the past and aware only of the sense of danger, lack of power, isolation and helplessness experienced at the time of the trauma. They would feel very threatened by the emergence of the traumatised part, as if still having the same need to safeguard the rest of the self by keeping the experience both out of consciousness but also, unknown to external others. They had a very important protective role in maintaining the dissociation. Another denying part would be likely to have identified with the perpetrators’ attitudes towards the traumatised part of the self, and then used these attitudes (threats, tone of voice, perceived power, etc) as tools to keep the repression in place. Such a part often feels a sense of guilt towards the other parts, and a fear of rejection by them, when the memory of the traumatic experience does break through.

The first task may well be to communicate with these parts until they develop enough trust in the therapist, to, at least loosen their grip somewhat on the dissociated material. The denying parts need to be:

valued for the vital nature of their role in helping the whole of the rest of the person to have survived by keeping this material hidden away,
relieved of the intolerable burden of having been on guard duty for all those years,
brought into the safety of the present,
understood, validated and, when ready, to negotiate a new role.

The Abreaction

Then, as the balance of pressures gradually changes, the previously hidden traumatic experience is allowed to surface in the form of an abreaction in the therapy situation.

Because the unprocessed flashback material is frozen in time, the client will be drawn back into that time, as if she were still right there. Part of the preparation needs to be developing the experience of co-consciousness, so that while experiencing the flashback, the client is also aware of the present and its safety. The main task of the therapist during an abreaction is to maintain vital contact with the present, and to hold that for the client. When an abreaction begins to unfold, the therapist may keep speaking to the client, with such messages as, ‘It’s not happening now’, ‘You’re safely here in this room with me’, ‘It’s safe to let it come through now’, ‘You will survive because you did survive then’.

The therapist can let her know that as it’s not actually happening now, the experience can be interrupted, she can take a pause from it, if she feels that would be helpful. She can be asked to give a hand signal to show if she chooses to do that, and, if so, then the therapist helps her to ground herself in the present for a while until she is ready to go back into the experience (if she feels that is what she needs to do). The therapist is providing a strong sense of safety and containment in doing this, and it helps to give the client a sense of mastery over memory material. It may also be appropriate (if previously discussed and agreed with the client) to offer a hand to hold, so that there is a physical anchor to the present, as well as the sound of the therapist’s voice.

In adaptive information processing theory (Shapiro 2002), the linking of the neural networks holding the traumatic material, with present healthily adapted networks is the foundation of the adaptive resolution of traumatic experiences. This is partly why an often lengthy period of preparation and stabilisation is needed before working with the traumatic material. There needs to be easier accessing of, and/or building of secure enough ego-strength and grounding in the present. The development of the relationship and the client’s ability to internalise it, is vital to such a foundation, and may sometimes take months or years before the client is ready. It is often very hard for a deeply damaged person to internalise much of the secure relationship, and it requires time, patience and commitment on both sides.

I have written this article from my own experience with clients suffering from DID, but also recognising that I have learnt, consciously and unconsciously, from my clients, from others’ experiences, through reading and training. Each client is unique, and one adapts the way of working to each client. Some of what I have written above may not be relevant to the next clients I see, so I recognise, may also not be relevant to your clients, but I hope something of it may be useful.

I would be very pleased to hear of others’ thoughts and experiences on handling flashbacks or abreactions, so we can learn more together.

Shapiro, F (2002) EMDR as an Integrative Psychotherapy Approach: Experts of Diverse Orientations Explore the Paradigm Prism. American Psychological Association, Washington.

Nel Walker

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Postal and Email Counselling

Some thoughts shared from the experience of Louise Lewis who has been involved in postal and email counselling since 1988. This kind of counselling may be a very helpful starting off point or extra support for people suffering from the effects of severe trauma in childhood. Or it may be an idea that readers may want to consider developing themselves. Louise may be contacted for further information about this at postalcontinuity@hotmail.com. (Ed)

General Points

Postal or email counselling can be used in various ways and for different purposes. The following comments are an attempt to convey the nature of this type of work as it has developed, from our experience within the approach and framework of our organisation.

Counsellors working in this way need counselling skills, flexibility and an ability to engage in 'conversation via writing', picking up and expanding on points where appropriate, and perhaps matching the person's style. They also need the ability to be working in the dark to an unusual degree.

There is no average period of corresponding, and we may remain in some
form of contact with clients for a number of years, receiving only an occasional update or postcard. Sometimes clients write in again if the going gets tough.

Letter and tape conversations are conducted from the beginning on the basis of not referring to past correspondence, working from memory or checking back with the client regarding something previously discussed, and this seems to work well and naturally.

We tell clients that letters are not kept long-term. They are shredded on a regular basis, and any tapes are cleared.

Counselling is informal in nature, but is not encouraged to run its course without a critical eye from time to time. We ask if any other form of help has been tried and what approach they feel suits them, and work around that. People do a lot of the work themselves, but someone else showing interest and support can make a significant difference.

In September 1999 the British Association for Counselling and Psychotherapy published a very informative booklet 'Counselling Online: Opportunities and risks in counselling clients via the Internet.' ISBN 0 946181 78 0 or see www.bac.co.uk.

Points in favour

Writing things down on paper can help clients consider their options better, whether or not they actually send a letter.

Interaction of a generally supportive kind, can lead to correspondents establishing better boundaries for themselves.

Some find it hard or impossible to talk about their problems in the early stages. Writing to someone they don't know may be easier to do.

Correspondence can build up to the point where the client feels able to
look for extra help locally, or for a specific form of help.

Information on other resources can be provided.

Some correspondents may already be in a counselling, therapy or support situation, yet find it helpful to have some other contact, especially if the therapy relationship is not working well, or is drawing to a close. The postal counsellor needs to fit around whatever else is going on for the client in terms of other therapy and the person's life and circumstances.
Postal contact can be especially useful for a client living in an institution.

A confidential service is offered, although clients may need to guard confidentiality at their end, if there is risk of mail being read by someone else.

Time to reflect on a reply before it is sent.

Correspondence can progress into talking on tape in both directions, like a delayed phone call.

A personal, organisational or a forwarding address can be used.

Neither the counsellor nor the client in postal or email counselling is tied to a time or place.
Inexpensive to run and for clients to use.

Some points to consider as possible disadvantages

Misunderstandings can arise, and we ask clients to come back to us if there is anything that has been misunderstood, or they are unhappy about or wish to ask.

Confidentiality may be a problem if there is a risk that correspondence may be read by someone else.

A client may feel let down in some way because their expectations of us are not being met, and we ask them to read our general disclaimer about responsibility before becoming involved.

Louise Lewis postalcontinuity@hotmail.com.

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Some Reflections on Containment

“The behaviour is not the problem, it is the solution. So what is the problem?” (Norma Howes at the TAG conference “Dissociative identity disorder and working with survivors of trauma and ritual abuse” at Swanwick in January 2000). Norma’s statement provides a refreshing perspective indicating that survivor’s behaviour may be less abnormal than we may be used to thinking. It may well be an attempt to regulate some difficult life experiences. It may be that the difference between sanity and madness is less to do with the degree of distress experienced in one’s life and more to do with one’s capacity to express it. Only then can one start to make sense of the confusion, pain, anxiety and fear that is felt.

The importance of “containment” as a means of providing a sense of safety for the client to explore feelings that may otherwise be experienced as overwhelming and confusing cannot be under-estimated. Containment is often about “holding” the alarm, confusion and pain of unfamiliar or overwhelming feelings.

Containment may be described as the capacity of one person to stay with and psychologically and emotionally hold the distress of another person in such a way as to allow it to be coped with. In the words of Patrick Casement in his chapter on key ‘dynamics of containment’ “… what is needed is a form of holding, such as a mother gives to her distressed child. There are various ways in which one adult can offer to another this holding (or containment). And it can be crucial for a patient to be thus held in order to recover, or to discover maybe for the first time, a capacity for managing life and life’s difficulties without continued avoidance or suppression.” (1985)

The counsellor will need to manage his or her own sense of uncertainty and confusion in order to be effective in assisting the client in managing their own feelings. If the counsellor can provide the confidence and presence that enable a client to believe that his or her difficult feelings can be managed, explored and understood then the client is less likely to resort to unsatisfactory coping mechanisms or to escape into a delusional private world.

In order for containment to be effective the counsellor will need to have some sound models of human functioning and an understanding of the developmental process. Without these they will risk being drawn into the client’s state of “alarm and confusion” and absorbing the client’s sense of feeling overwhelmed. The models can provide the map and compass to help work out where in the process the client is, and also where he or she needs to go in their journey of recovery. Models can provide the framework within which you both exist and can also provide the assurance that even if things don’t seem very clear, it does not mean he or she cannot find a way through.

One thing more alarming for the client than his or her own feelings, is other people’s fear of the client’s feelings. A counsellor’s capacity to hold the uncertainty of a client’s situation and his or her “difficult” feelings will be central to sound containment within which the client is enabled to make progress.

Good supervision is essential for the counsellor committed to providing effective containment for their clients, and, where necessary, a counsellor’s own therapy. Another very valuable resource is that of keeping up with the rapidly changing developments in the field of early life trauma studies. These factors together with listening to the client may provide the essential ingredients for containment.

References:
Casement, P (1985) On Learning from the Patient Routledge.
Casement, P (1990) Further Learning from the Patient Routledge.
Wosket, V (1999) The Therapeutic use of Self – Counselling Practice, Research and Supervision. Routledge.

Mike Fisher

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Affect Regulation Skills contributed by Nel Walker
(Based on the work of John Omaha - 2004)

Nel will be presenting a brief experiential workshop based on this material at the TAG Conference in April.

No classes or tutorials are ever offered for handling emotions, yet it is something that is absolutely vital to our well being; our health, our sense of self and all our relationships depend upon it. We suffer if others close to us have problems themselves with it. Deficit in the area of affect/emotion regulation is a large factor in many, if not most, relationship problems, in violent behaviour towards self and others, phobias, addictive behaviour and depression. Affect/emotion regulation skills normally develop naturally within a good enough attachment relationship with the primary caregiver in the child’s earliest two to three years of life, and as healthy brain development unfolds. Other factors are: genetics (inheritance sets the thresholds for affects) and the child’s socio-emotional history from 3-4 years until adolescence. The person fortunate enough to have developed affect regulation skills in good enough measure is not usually aware of this valuable skill but often puzzled by others who have not been so fortunate. The skills usually operate unconsciously.

Whilst it is recognised that a good psychotherapeutic relationship provides for the unconscious transmission of self-regulation which can lead to some extent to the remediation of a client’s early deficits, Omaha proposes that they may be transmitted in psychotherapy in a more active way, and that the means to do this early in the therapy relationship also gives an opportunity for the client to experience flexibility and attunement from the therapist, leading to a greater sense of safety and security. Omaha also asserts that we have a responsibility to teach or transmit these skills as they are a vital part of preparing a client for working with traumatic material.

He emphasises the importance of this by pointing out the link with the child’s developing self-structure: ‘Affect regulation and structuring of the self are conjoint processes which cannot be separated.’ Clearly, any person suffering from a dissociative disorder (and also most with any significant psychopathology and a large proportion of the general population too) will have problems with regard to affect/emotion regulation. Any positive learning of affect regulation skills in treatment will contribute markedly to repairing deficits in the client’s self-structure and also helps to widen the window of tolerance for processing traumatic material.

Below are definitions of the words ‘affect’ and ‘emotion’ as used by Omaha, and as originally developed by Tomkins (1962 and 1963) and Nathanson (1992).

‘Affects are the genetically hard-wired physiological building blocks from which feeling, emotion and mood are constructed.’ There are ‘nine basic affects: excitement, joy, startle, fear, anger, anguish, shame, disgust and dissmell’’ [dissmell: an affect which forms a foundation for the emotions ofdisgust in all its wider ramifications, such as shame, self-loathing. Ed.] (Nathanson 1992).

‘Emotions are affects modified by experience. In emotion, affects are assembled with images, memories, cognitions, introjects, and other affects.’ ‘As Nathanson (1992) wrote, “affect is biology, emotion is biography” (p.50).’

People may be overwhelmed by specific emotions by emotions in general, and also by the fear of experiencing any emotion at all. Some may experience panic attacks, or angry outbursts which they feel are outside of their control, or else others may be very flat or numb emotionally, or the emotion becomes displaced, projected or maybe being expressed somatically or in self-harm. Some clients, especially those with dissociative disorders may alternate from one state to another.

In some cases emotion regulation skills develop adequately in childhood, but subsequent overwhelming traumas seriously compromise this skill.

Affect regulation is the capacity for affects and emotions to be actively and appropriately available, for one to feel safe and grounded whilst feeling the emotion, for the emotion to be experienced at a level that is appropriate to the circumstances, and under the control of cognitive evaluation of the situation, but, more than that, affect regulation provides a basis for developing a secure self-structure.

Omaha, drawing on the recent work of many well-known authors and researchers in the field, presents a way of working with clients, which he calls Affect Management Skills Training (AMST), which can be used with clients to regulate affects. I have been using his model with a majority of my clients in one form or another for about five years, especially with victims of trauma. The client usually finds that he/she can use the skills outside of sessions, thereby reinforcing them and gradually developing a sense of mastery, leading to the unconscious operation of the skills as new neural pathways are developed which seem to fill the templates in the brain for the establishment of this natural ability.

In AMST the therapist communicates with the client’s right brain through the use of imagery and felt body sense, and links these with cognitions. There are several components involved. The first skill to be transmitted is the ability to confine disturbing material in an image of a container.

The second is the building in of a bodily-experienced locus of safety or comfort.

Then follow a series of skills for regulating specific affects. The client is helped to choose a target affect at a low level of intensity, on which to focus, then learns skills for recognising, noticing and tolerating the affect, whilst experiencing being grounded and in the present, and then the ability to down-modulate the affect to a chosen and ecologically appropriate level.

Usually a client is quite surprised at the difference, and is enthused to practice these steps on their own until they become automatic and body-led. In most cases this leads to the ability to regulate emotions without being cognitively aware of it.

Emotion management increases the integrative capacity and level of psychological tension required for processing trauma, so needs to be in place before any uncovering or treating of traumatic experiences is attempted.
John Omaha originally published a paper on AMST in 2001 in the arena of trauma therapy, specifically EMDR, and has continued to develop his thinking in conjunction with other therapists as they have discussed to queries and problematic case studies on his internet discussion forum and also through the workshops he presents. He is experienced in working with clients with DID and although AMST has built-in flexibility and responsiveness to the individual client’s needs, suggests further modifications in using this way of working with people with DID. Nel Walker

References:
Nathanson D L (1992). Shame and Pride: Affect, sex and the birth of the self. New York: Norton.
Omaha J (2004). Psychotherapeutic Interventions for Emotion Regulation: EMDR and bilateral stimulation for affect management. New York: Norton.
Tomkins S S. (1962&1963) Affect / imagery /consciousness. Vols. 1&2. New York: Springer

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The Impact of Attachment Trauma on the Helper

Understanding the impact of childhood trauma on attachment and the regulation of emotional arousal informs the process of healing (e.g. Solomon and Siegel, 2003). It is useful to apply this expanding area of knowledge to the impact of working with attachment trauma on the helper's own attachment system and capacity for emotional regulation. 'Helper' is used here as an umbrella term for a variety of roles, both professional and voluntary. To provide a secure enough base for the survivor's healing journey, the helper needs to be able to regulate their own emotional state and to have a secure enough base of their own. Studies (e.g. Dozier et al., 1994) have highlighted how different care giving responses elicited in helpers according to their attachment style effect the therapeutic process. For example, regardless of client need, helpers with a preoccupied style may intervene more while those who are dismissive may tend not to.

As helpers, we would probably all like to think of ourselves as secure enough to respond appropriately to the client's attachment needs whatever our own attachment style. However, I suspect that anyone who stays the course as a companion on the survivor's journey will find it hard, at least at some point, to avoid becoming over-aroused in attachment terms.

It is both normal and inevitable that the helper's attachment system will be activated by intense insecure ambivalent, avoidant or disorganised care seeking by survivors whose attachment needs have been exploited and betrayed by their abusers. For example, hearing the experiences of a survivor of satanic ritual abuse can lead to anxious, over-involved care giving or to avoidance and disengagement.

Persistent exposure to emotional deregulation in the absence of adequate care, leads to burnout and secondary traumatisation. This causes not only personal and professional distress, but also restricts the capacity for reflection and exploration so essential to helping work. There are several routes by which we can maintain and restore our emotional equilibrium and with it, our reflective and exploratory capacities.

Van der Volk (Counselling and Psychotherapy Journal, May 2004, 10-13) speaks of the particular need of trauma workers for self-soothing, restorative activities such as meditation and yoga. Such physical, reflective and spiritual activities reduce stress, the volume of stress hormones in our brains and help us to hold on to a sense of meaning.

As well as self-care, we also need good enough care giving. This might come from someone perceived as older or wiser but can be from a variety of sources as long as it is sufficiently reliable and companionable. For example, on exploring my experience as a professional caregiver in a threatening and deregulating environment, I identified the absence of supportive and companionable peers as a major source of distress and the support of a few key people as a key component of recovery (Richardson and Bacon, 2001).

Those survivors, who are severely symptomatic, and especially isolated struggling to be self-reliant or stigmatised by other sources of help are a particular challenge to our capacity for self-regulation. How do we respond without either abandoning the survivor or becoming the sole, overburdened caregiver? Thinking creatively and forming 'virtual' teams (e.g. with referrers, other practitioners involved with the survivor) or offering packages of assessment and consultation might be more constructive than saying ‘no’ or more realistic than asking the survivor to find a support system as a precondition for counselling.

Identifying the challenge of emotional regulation may be a helpful way to view colleagues who struggle with their boundaries or who fail to engage in difficult terrain. We can also make decisions on training, conferences and other professional activities in the light of how far they are likely to be stimulating and supportive without being too deregulating. If we can stay in touch with the complex drama going on in our own brains then we will be better equipped to attune to the narrative of trauma being played out in the lives and minds of those who seek our help.

Sue Richardson

References:
Dozier, M, Cue, K. L and Barnett, l. (1994) Clinicians as Caregivers: Role of Attachment Organisation in Treatment. Journal of Counselling and Clinical Psychology, 62, 4, 793-800.
Richardson, S. & Bacon, H. Piecing the Fragments Together. In: Richardson, S. & Bacon, H. (Eds.) Creative Responses to Child Sexual Abuse: Challenges and Dilemmas. London: Jessica Kingsley.
Solomon, M. F. and Siegel, D.J. (2003) Healing Trauma: Attachment, mind, body and brain. London: Norton

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Are you a Brain Organiser?

According to recent neurobiological findings, if you are a counsellor or psychotherapist, then you are a Brain Organiser, as you are involved in a process that changes neural organisation, structure and functioning. Neuroscience is providing us with an increasing understanding of what happens in the brain during psychotherapy, and strongly validates it.

The therapeutic relationship, whether one thinks about it or not, has always had the effect of changing the client's neural organisation. The art of psychotherapy, which has evolved quite separately from scientific knowledge, seems to be doing mostly the 'right thing', according to brain scientists, who's work is bringing knowledge and understanding of what happens at the neural and physiological levels in the therapeutic relationship. These affirmations of what psychotherapists and counsellors have already been doing, largely intuitively, may have many benefits including the following:

A greater feeling of confidence in what we are doing by providing a safe, empathic, attuned and containing relationship, thus helping one to hold steady and stay grounded even when times are challenging beyond the norm.

One would be working from a firmer foundation from which the thinking and choice of intervention is likely to be more helpful. For instance, if we understand how the interaction with the client can have a regulatory effect on the client's affect system then we will be able to refine what we are doing and so do it better. We will be more able to help clients themselves to understand, where appropriate, what is happening in their own brain, mind and body when, for instance, he or she is triggered and has a panic reaction, or what is happening when experiencing disturbing ambivalence in the relationship with the therapist. Insights such as these can help to empower the client, to normalise their symptoms and help them to be more of a curious observer of those symptoms rather than being caught up in and taken over by them. When clients begin to understand that their problems and symptoms in the present are based on normal and recognised responses and adaptations to their abnormal early experiences they are likely to feel more self-accepting and hopeful of a way forward.

New understanding of how the mind-body system works is opening up new ways of working which can be even more effective and focused without minimising what we have always known about the importance of the relationship. There is a buzz of excitement caused by the growing synthesis between the art and the science of psychotherapy, as it appears to be offering potential for greater strides forward in working with very damaged people.

There is an energising and empowering bridging of the gap between the clinical field of mental health and the independent field of neuroscience. Margaret Wilkinson, a Jungian analyst and author, presents counsellors and therapists with a challenge. She writes: "Sound therapy requires an understanding of mind, brain and body. Now such knowledge is available, nothing less will do." (Wilkinson 2006) She also asserts that knowledge of current neuroscience can enable clinicians to, "come to a clearer understanding of why they do what they do, especially in relation to the unconscious, empathic, dynamic aspects of work in the transference and counter transference".

Here are some quotes I came across recently describing psychotherapy in terms of this new conceptual framework: "Psychotherapy is currently conceptualised as being directed towards the mobilisation of fundamental modes of development and the completion of interrupted developmental processes." (Schore, 2006 Workshop)

Cozolino proposes that people who seek psychotherapy have, at the basis of their needs, the problem of neural networks, which have been underdeveloped, unregulated or un-integrated. "At the heart of psychotherapy is an understanding of the interwoven forces of nature and nurture, what goes right and wrong in their developmental unfolding and how to reinstate healthy neural functioning. When psychotherapy results in symptom reduction or experiential change, the brain has, in some way, been altered." (Kandel 98, from Cozolino 2002)

"Psychotherapy is an attachment relationship capable of regulating neurophysiology and altering underlying neural structure." (Amini et al, Psychiatry 1996) This is what we are doing!

Almost all of the above, applied to psychotherapy, is parallel with the relationship between mother and baby and the shaping of the developing brain in that interaction, for better or worse.

But a client is not a baby!

Of course, we are not just dealing with the problem of 'underdeveloped, unregulated or unintegrated' neural networks. Our severely damaged clients' brains have been badly messed up, by the effects of neglect, misattunements, trauma, shaming, lack of safe containment and so on. In the developing brains quest to bring order, meaning and adaptation out of harmful and inadequate experiences, development will naturally have taken place, but dysfunctionally, affect would be dysregulated and many neural networks would remain unintegrated and prevented from integrating by conditioned fear. The inadequate and traumatising raw materials of experience offered by such toxic parenting and/or other damaging cultural forces, have led to the many problems and symptoms we see in clients with dissociative identity disorder or complex posttraumatic stress disorder, symptoms that affect every level of functioning of the brain, mind and body.

The science of psychotherapy is holistic

Knowledge from the field of science underlines the interconnectedness of body, brain and mind, and the significance of involving all three brain levels (cognitive, limbic and sensorimotor), and the body in psychotherapy. It has also helped to shift the emphasis of where we need to work towards the sensorimotor and limbic structures of the brain, as being key in understanding what is happening, and away from the previously assumed greater significance of the cognitive areas, although all areas are important and interrelated.

The challenge of neuroscience

Traditional good psychotherapy models that are based on a safe, reliable, attuned, and contained relationship have been validated by neuroscience and the field is also being offered the tools for developing more effective psychotherapy. Could psychotherapists improve on the effectiveness of neural reorganisation by providing more clear raw materials, especially in some areas of experience such as affect regulation or the sense of continuity through time, in order to help the client towards a clearer reorganisation of their internal map or sense of self? Some of the most exciting developments that I have come across recently that seem to offer such ways forward, which are practical as well as grounded in current neuroscience, are in the following areas:

Sensorimotor Psychotherapy - developed by Pat Ogden and for which there are training course now running in the UK. More information about the concepts can be found at: www.sensorimotorpsychotherapy.com

Structural Dissociation of the Personality as a result of Trauma

- no specific trainings available in the UK at present, but the book 'The Haunted Self', by Nijenhuis, Steele and van der Hart, has been published by Norton and provides some very helpful knowledge and tools to all those who work with traumatised people.

Emotion Regulation - the best book I have come across in this field, and one that is based on all three levels of brain functioning, is John Omaha's 'Psychotherapeutic Interventions for Emotion Regulation' (2004). Norton.

Lifespan Integration - developed by Peggy Pace in the USA. Training in UK beginning in 2007. Her book is available from the web site: www.lifespanintegration.com

There are many others too who are developing ways forward in psychotherapy and counselling based on the new synthesis between the art and the science of psychotherapy. It may be useful to share more knowledge of different developments with each other. Perhaps you could add to this list, keeping us in touch with ways in which an increasing synthesis with the world of science is affecting the theory and practice in your areas of work and experiences. Wilkinson suggests that the integration of neuro-scientific data and psychodynamic models will lead to a resurgence of imaginative and thoughtful clinical work. Allan Schore adds "What better outcome of a paradigm shift than that?" (Wilkinson 2006, Foreword)

References

Amini et al (1996) 'Affect, attachment, memory: contributions towards psychobiologic integration' Psychiatry, 59, 213-239

Cozolino L (2002) 'The Neuroscience of Psychotherapy: Building and rebuilding the human brain.' Norton, New York.

Wilkinson M (2006) 'Coming into Mind: The mind-brain relationship: a Jungian clinical perspective. Routledge, London.

Schore A (2006 Workshop) 'The Art and the Science of Psychotherapy.'

Nel Walker 2006 Clinical Psychologist in Private Practice

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An Integrated Overview of Functioning

In order to best appreciate and understand the effects of trauma on people it is crucial to recognise the role played by different elements of our being and especially the relationship between them. The key elements could be summarised as follows:

The role of the brain as the communication and control centre of the body. The complex structure of the brain controls organs and glands, holds our capacity to function, think, move, feel, react and undertake a myriad of tasks and activities. The brain is instrumental in the formation of memory, speech and language and in organising all the activities required for our survival. In crisis situations the more established (and more primitive) parts of the brain takeover and override the later (but more developed) parts of the brain. In trauma these can become the default positions.
The nervous system is the communication network in the body. It has some pre-programmed (autonomic) parts of the system that are automatically triggered into action at the signals of danger.
The neurotransmission system is a range of both simple and complex chemical messages that move between the brain, nervous system and body. Some of these neurotransmitters, steroids, hormones and peptides are responsible for very powerful reactions within us. Whilst there is often a feedback loop to stop us being flooded with unnecessary amounts of these chemicals these do not always work, especially if we have overwhelming experiences like trauma.
The body is the container within which all our living activity takes place. It is not only made up of muscle and bone but also a range of life supporting organs and is covered with skin. The body plays a key role in registering and recording our experiences and in holding cellular memories within the millions of nerve cells that are present in every part of it. The body is therefore very significant in registering our experiences of trauma, containing the unresolved effects it has on us and in providing the sensations and movements that enable us to resolve and recover from traumatic stress.
Our thoughts, consciousness, spirit and being all have a significant part to play in resourcing, resolving and recovering from trauma.

The world of therapy is still straddled between the dualistic thinking that dominated western approaches to understanding since the writings of Descartes and to incorporating the rapidly escalating insights and knowledge made available through brain imaging and neurobiology. Dualism is still widely reflected in the many "singular" modalities within the therapeutic world that put an emphasis upon "Cognition", "Behaviour" or "Emotions" as the prime focuses for change, with little recognition of the role of the "body" in the process or any regard to the role of the "spirit". It is without a doubt that nearly all modalities have something to offer the process of recovery, but until more holistic overviews are achieved, and more integrated approaches adopted, the potential of full recovery may not be realised or progress may be slower than necessary.

There might be even greater danger in some Christian inspired counselling approaches that put a very strong emphasis upon Descartes' belief in the dominance of "thought, reason and the will" as that which makes us human, at the cost of understanding "what" may be happening for some people. This may well account for the number of survivors who emerge from those religious settings that have sought to help them, only to experience re-traumatisation. It is important to realise that it is not the intentions that were wrong only the understanding and interpretation of what was happening that was in error.

Hopefully with greater and increased awareness in both clinical and pastoral settings distress and re-traumatisation will be less common. We all need to have a commitment to continued professional development (CPD), have an open and enquiring mind, and to realise that what we understand or believe now may be different in a year or two's time as greater understanding emerges with new insights and knowledge.

Mike Fisher, 2006

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States of Consciousness

Our states of consciousness are influenced by our brainwave patterns and by our left and right brain hemisphere activity, amongst other things.

Brainwave wave bands can be understood as:

- Gamma Waves (over 30 Hz frequency) - learning, memory, perception
- Beta waves (12 to 30 Hz frequency) - anxious thinking, focused activity, REM sleep
- Alpha waves (7 to 12 Hz frequency) - awake but relaxed
- Theta waves (3 to 7 Hz frequency) - drowsiness, early sleep, trance states
- Delta waves (1 to 3 Hz frequency) - deep sleep
- Slow waves (below 1 Hz frequency) - non-activity or preparing to move

As part of a regular cycle we both change our brain wave pattern and move from left brain cognitive thinking to right brain processing every hour and a half for about twenty minutes. This is usually when we become restless, distracted, and fidgety and can end up daydreaming. This may explain why meetings that run longer than an hour and a half without a break are less productive.

A similar process goes on in our REM (rapid eye movement) sleep in a more extensive way. This is one of the ways we process the extensive amount of data, information, perceptions and thoughts that we take in. It is also why we so often seem to have solutions, creative thoughts and enhanced learning when we have had a break or a good nights sleep. The right hemisphere of the brain is much more associated with creative and abstract thoughts and activities and is much more open to suggestive input.

A similar process happens when we become engaged and focused on an activity that draws on this side of the brains activities, such as a hobby or pastime, watching a film or reading a book. The consequences are that afterwards we feel more satisfied, relaxed, fulfilled and more energised to take on life's demands. This is also why regular rest and play are essential for a sense of well being and effective functioning.

Altered states of consciousness can be described as 'dissociated' or 'semi-hypnotic' states, where our consciousness excludes awareness of other 'outside' information, stimuli or activity. This is where we experience being in another world of our own thoughts or experiences. Our bodies and brains move through different levels of brainwave activity through the day and night depending on what we are doing.

Survivors of trauma experience pathological dissociation, as a result of the trauma, and may suffer from structural dissociation of the personality. The dissociation becomes a mechanism for coping with the unresolved intrusions and avoidance responses that occur as a result of being overwhelmed by a traumatic event. Activities or events that lead to the defensive barriers or gates of dissociated states being bypassed can lead to the survivor experiencing emotional flooding by the traumatic experiences and going into states of hyper-arousal or hypo-arousal. Other triggers such as music, visual imagery, lying down horizontally, prayer ministry, meditation, massage and touch can all be activities that might lead to the breakdown of these defenses.

This can account for traumatised individuals experiencing mood swings, emotional states, blanking out, "switching" or responding in a perplexing, uncharacteristic or incongruent way. It may also be the reason why some survivors find settings such as church, which would normally be a place of comfort for many people, difficult or distressing.

If this happens the survivor needs to be helped to be grounded and consciously aware of their surroundings. It is important that they are enabled to feel physically safe and are brought back into their "window of tolerance" from states of hyper-arousal or hypo-arousal. It is also important that anyone for whom this happens is not made to feel more guilty or ashamed than they already do. Only then will they be able to regain their equilibrium and an increasing capacity to cope with life's demands.

Mike Fisher, 2006

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Working Approaches

Helping to change the world

Working with survivors of ritual abuse

A Three Phase Approach to Recovery

Some Thoughts on Handling Flashbacks and Abreactions in Therapy

Postal and Email Counselling

Some Reflections on Containment

Affect Regulation Skills contributed by Nel Walker (Based on the work of John Omaha - 2004)

The Impact of Attachment Trauma on the Helper

Are you a Brain Organiser?

An Integrated Overview of Functioning

States of Consciousness

Affect Regulation Skills contributed by Nel Walker
(Based on the work of John Omaha - 2004)