Complex Trauma And The Safe Negotiation Of Risk

WHAT IS GOOD THERAPY?
The most direct questions are often the most challenging! And so it is with this one. I recall the comment (confronting on a first hearing) that you don't go to therapy to feel good. Rather you go to feel at all. Working as I now do in the area of trauma, that adage has new layers of meaning. Accumulated unresolved stress (especially if it dates to childhood) can lead to dissociation, which insulates from the depth of the pain by compromising the capacity to feel per se.

`Good' therapy, then, helps to restore (or perhaps to acquire) the capacity to feel. Which leads to the conundrum and irony that new or renewed ability to experience emotion entails the capacity to tolerate grief, anger and the less comfortable emotions from which we may have been fleeing in the first place.

This also means that good therapy must be safe therapy. Not safe in the sense of avoiding all risks (which would defeat the purpose just noted). But safe in the sense of ensuring, in so far as we can, that clients have the inner resources (which can be fostered and learned) to begin to access feeling without becoming destabilised.

Significantly, safety and stabilisation comprise the first and critical phase of the recommended treatment for complex trauma (the others are `processing' and `integration' respectively). `Complex', as distinct from `single-incident' trauma is cumulative, underlying and interpersonally generated. One of the key differences in effective treatment of these contrasting types of trauma is the particular need, in the case of complex trauma, for avoidance of precipitate processing in the absence of client capacity to self-regulate.

Fortunately and excitingly, we now know that the ability to self-regulate can be learned. But much `not good' therapy has wrongly assumed a coherent subjectivity to start with (i.e. rather than the disequilibrium which stems from unrepaired interpersonal stressors, and which so disrupts daily functioning and quality of life). In so doing, and notwithstanding the `good intentions' of the therapist, clients can be re-traumatised within the therapeutic context itself. `Risk' and `self-regulation' thus need to be paired at all times; the former is contingent on the latter.

Ability to access our feelings (safe in the knowledge that even when challenging and painful, they can be experienced without the need to escape) evokes a powerful text published as long ago as the seventies. If You Meet the Buddha on the Road, Kill Him!' (subtitled The Pilgrimage of Psychotherapy Patients) is confronting for obvious reasons! Its author, Sheldon Kopp, was explicit that `[a]ll of the truly important battles are waged within the self' (p.7) and rightly sceptical of the perennial desire to locate `meaning' elsewhere. He is probably correct that `[e]verything good is costly', and that development of the personality `is one of the most costly of all things' (p.10). It requires, he contends, `your innocence, your illusions, your certainty'.

This is all the more reason why `good' therapy should be as safe as possible (i.e. to provide a context in which such losses are not experienced as unbearable, and ensuing benefits are felt to be rewarding). Kopp is less persuasive, I think, in his reiterated and unqualified claim that patients seemingly unwilling to accept responsibility are trading on the status of victim. His robust therapeutic style would certainly not have been for the faint-hearted! And I fear it may have been re-traumatising - not just disconcerting - to those whose starting place was that of dysregulation (which we now know to be a devastating legacy of childhood [complex] trauma).

Interpersonal neurobiology (`the neurobiology of attachment') means that we now know so much more about the complexity of subjectivity, and the  contextual conditions on which its development and flourishing depends. Good therapy should be informed by the growing evidence base of these important theoretical and practical insights.  Self-knowledge remains a goal of the `pilgrimage' of psychotherapy. But if construction of the self has been disrupted by unresolved overwhelming experience, a delicate and paced approach is the gold standard for therapy to qualify as `good'.