Mindful Monday

I thought I’d try something a little different here, as part of my ongoing desire to blog more frequently. I considered titling this series “Wordless Wednesdays” because I especially want to share evocative images with you. I find at times in trauma therapy that words fail us, or we need to step outside of the traditional form of communicating about and processing therapy. However, knowing me, I just don’t think I could do away with words altogether! So I chose another day to make my alliterative title plan work and named this series “Mindful”.

As Treating Trauma has developed over the years, I’ve come to appreciate what an important role mindfulness can play in trauma therapy and in all our lives. Finding a way, even for a moment, to be present with what is, in this moment, can have transformative, healing power.

So my plan is to share some things with you each Monday: a photo, an image, a quote, a poem. I may say a bit about them, too. Mindful MondayMany people turn to nature to practice mindfulness. Tucson is full of many unique forms of nature which often include vivid sunsets and sunrises. Watching a sunset like this reminds me of the possibility of the spectacular in any moment, and of its fleeting nature. Mindfulness encourages an awareness that everything passes: we can be with what is and gently make room for the next thing to come.

I hope you enjoy this new series and as always I welcome your thoughts!

Posted in Health, Mental Health, Mindfulness, Relaxation, Self-care, Trauma, Tucson | Tagged , | 2 Comments

Breaking Silence: Talking about Trauma

Breaking SIlence: Talking About TraumaHave you heard any of the following: break the silence, stop the silence, speak out? In activist and healing circles, survivors are often encouraged to talk about their traumatic experiences. Why is this the case?  Should you talk about your abuse?

As is so often the case in healing, it is a matter of when, how and to whom.

Some survivors have spent years keeping their abuse secret, or they have disclosed to someone who responded poorly, perhaps expressing disbelief or victim blaming. Not telling anyone about your abuse can be a form of avoidance coping.  Avoidance can worsen post traumatic symptoms in the long run. It can even prevent you from fully understanding your experience.

Some trauma survivors may go to the other extreme and feel compelled to tell their story indiscriminately. This form of talking is often somewhat dissociative in nature, and does not reap the healing benefits that come from processing trauma.  Some survivors are not able to make healthy decisions about who to tell or anticipate what the consequences of telling might be, possibly resulting in retraumatization. I work with clients in therapy on developing the idea of zones of closeness, from your most trusted inner circle to acquaintances or co-workers on the outer edge. This included learning to make decisions about who deserves  inner circle status!  While it might be a very positive experience to share details of your trauma history with your closest friends or support people, can you see how it might be different with a co-worker or a neighbor?

Timing matters too. Do you lead with all your most vulnerable information at the start of a friendship, or do you share a bit over time, assessing the other’s reactions, trust worthiness and ability to be emotionally present with you? Do you notice whether the other shares personally with you as well?

How does disclosure work online? Blogging, survivor forums, and social media can all be powerful ways for survivors to educate themselves, receive validation, and find support. Some survivors choose to disclose specifics of trauma online while others do not. I think what is crucial is that you have an understanding of your intent, the impact of sharing on you (and others). Ask yourself, is this contributing to my healing or not? When sharing sensitive material online it is always important to remember how public it is. Would you feel okay if your anonymous identity was compromised? Could what you are writing pose any kind of safety risk to you?

Early on in your healing journey, perhaps journaling online privately or even on paper might work best.  For many trauma survivors  writing about traumatic material is easier than speaking at some phases of therapy.

For survivors with dissociative disorders internal consensus is also important. Do you know how all parts of you feel about you disclosing traumatic experiences? Can you communicate about that in advance or will there be surprises and retaliation in store?

As with so many things in trauma therapy and life in general, it is all about balance. Either extreme, never telling anyone or telling indiscriminately, could adversely impact your ability to heal. Talking about trauma is part of the recovery process. It can decrease shame, help you challenge irrational beliefs, and reduce post traumatic stress symptoms. Outside of therapy, learning how to share your abuse history and with whom is one aspect of  developing healthy, authentic relationships. When we share that which feels vulnerable, we form deeper connections.

Posted in Abuse, Childhood Abuse, Dissociation, Health, Mental Health, Psychologist, Sexual Abuse, Therapy, Trauma | Tagged , , , , , , , , , , , , , , , , , | 4 Comments

Treating Trauma and the Therapeutic Frame

Recently someone asked me a great question via Twitter. I love reader questions! They have prompted some of my favorite blog posts! (See: How to Avoid an Abuser: Understanding Grooming, Reader Question: Treating Emotional Numbness, Can Complex PTSD Be Cured?, What Comes After Connection?)

Sushipink wanted to know about how to handle in between session contact with clients with complex post traumatic stress disorder (CPTSD), and whether such contact is therapeutic or not. Such a great question and one many (all?) new therapists grapple with, specializing in complex trauma or not. As an aside, I cannot imagine a setting where the new therapist will not be faced with trauma, but that is a subject for another day.

Thinking about how to frame (geeky therapist joke intended) a response to that question took me back to my psychodynamic training and a key concept: the therapeutic frame. Therapists operating within certain schools of thought (like psychodynamic) believe that the therapeutic relationship is made possible by the existence of this frame. The therapeutic relationship is unlike any other in that it involves processing vs talking  and the internalization of capacities missed in childhood that were disrupted due to abuse or neglect. The frame allows this unique relationship to blossom.

What is the therapeutic frame? It is the things that we do as therapists, the structure that we create for therapy, that demonstrates our beliefs about how therapy works. It includes expectations about how we, therapist and client, will interact with each other and contribute to the therapy process. Perhaps you are more familiar with a similar term, therapeutic boundaries, although the frame is more than that. Some aspects of the frame are non-negotiable, based on our clinical understanding of how therapy works, our ethical guidelines, and personal needs (yes, therapist get to have needs too!). Other aspects vary with each client, and may change over the course of therapy with a particular client.

Boundaries are critical in therapy in general. They become that much more so when working with clients who have experienced early and ongoing boundary violations in the context of intimate relationships with caretakers. With survivors of complex trauma, establishing, maintaining, and at time negotiating the boundaries is a critical part of trauma therapy. It is important that the therapist have a theoretical basis for her frame and flexibility in adapting to the specific needs of each client. CPTSD clients are often hypervigilantly attuned to any potential boundary violations, or dissociated and unconsciously attempting to reenact earlier experiences. Either way, the issues of boundaries and the therapist’s management of them will play a key role in trauma therapy.

Pearlman and Saakvine, in their excellent book Trauma and the Therapist, recommend  these five strategies for us to keep in mind as we negotiate the boundaries of trauma therapy. (While they specifically address therapy with childhood sexual abuse survivors, I feel this approach is generalizable to any complex or developmental trauma work.)

  1. Having a clear theoretical framework for the therapeutic relationship and specifically for the boundaries and frame of this relationship with sexual abuse survivors
  2. Setting a clear therapy framework with each client
  3. Knowing ourselves and our own histories, weaknesses, and vulnerabilities through personal therapy and reflection during and between sessions
  4. Receiving consultation and supervision on a regular basis
  5. Discussing frame issues with clients openly and over time, especially when the client requests a change

Back to the question! So what about in between session contact? Is it therapeutic? Not? My brief answer, in typical therapist fashion I fear, is “It depends”.  It depends on so many things: the stage of therapy, your theoretical orientation, the boundaries you have negotiated with this particular client based on your understanding of their developmental level, the reason for the contact. As trauma therapists, our decisions about this are guided by our beliefs in general about therapeutic frame and boundaries as well as how we have negotiated these with a particular client.

Some questions to ask yourself about in between session contact could include:

  • does the client need it vs. want it?
  • is it time-limited or open-ended?
  • is it specific (for example in the case of emergency, and then what is the definition of emergency)?
  • is it sustainable by the therapist ( I learned early on that I could not function well if I took calls from clients in the middle of the night)?
  • is it serving the purpose of working through the trauma and helping the client develop greater internal capacity for coping or is it reenacting some part of  the trauma triad (victim-perpetrator-rescuer) or gratifying in the moment?
  • is contact being offered by the therapist or requested by the client?
  • what is the client’s developmental level? phase of therapy? experience with boundaries and boundary violations?
  • does the client have “parts” or dissociated aspects of self? what is the meaning of extra contact to all parts of the client? is it possible to know that at this point in time?

My approach when in doubt, is to err on the side of caution, or the side of stricter boundaries. When it happens, I do believe it is important to be specific about the nature of in between session contact: the form of contact, duration of time, what the client can expect from you during the contact, and whether fees will apply. Exploring the request for (or offer of) extra contact and the meaning of this then becomes another part of the therapy process, or, as we therapist like to say, “it’s all grist for the mill”.



Posted in Abuse, Childhood Abuse, Complex Trauma, Dissociation, Health, Mental Health, Psychologist, Sexual Abuse, Therapy, Trauma | Tagged , , , , , , , , , , , , , , , , | 4 Comments

Avoidance and Trauma Therapy

What does avoidance have to do with trauma therapy? Avoidance is a common coping strategy. In psychotherapy, when we talk about avoidance we mean strategies for avoiding unwanted or uncomfortable feelings. Avoidance is a natural and understandable response to a traumatic event. Who wouldn’t want to avoid reminders of a painful and overwhelming experience? Or attempt to avoid situations because you fear something similar could occur again?

The problem is, avoidance doesn’t really work. In fact, avoidance strengthens the fear and anxiety response! The more we avoid a place, person, or even feeling, the more likely we will continue to feel anxious about it and continue avoiding it. A vicious cycle!

Ongoing avoidance is one criteria required for a diagnosis of PTSD in the DSM V:

Criterion C: avoidance

Persistent effortful avoidance of distressing trauma-related stimuli after the event:(one required)

  1. Trauma-related thoughts or feelings.
  2. Trauma-related external reminders (e.g., people, places, conversations, activities, objects, or situations).

The presence of avoidance is diagnostic of PTSD and research has found that an avoidant coping style is related to increased PTSD symptom severity for sexual assault survivors.

Avoidance can happen within therapy too. Sometimes therapists collude in avoidance, for perhaps in an unconscious effort to prevent the client from feeling more pain. In trauma therapy avoidance can look like:

  • talking about any and everything but your trauma
  • minimizing the severity of your experience “other people have it worse than me”
  • forgetting to do homework in between sessions
  • forgetting or missing appointments

Trauma therapy is all about facing, being present with, and moving through your traumatic experiences instead of avoiding them. It involves processing your traumatic experiences by staying present with the associated feelings and beliefs. No small task! The payoff for this hard work  is decreasing the high intensity emotional charge while creating meaning.  A trauma-informed therapist of course understands to need to approach this work gently and with compassion. Avoidance exists for self-protective reasons. With help and support you can learn more effective ways to overcome trauma.

avoidance and trauma therapy



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Blazing a Path

Mass murder. Misogyny. Maya Angelou. Jane Doe. The Transgender Tipping Point.

These are the things on my mind and heart.

I’m reading, thinking, talking about the recent spree shooting murders in Isla Vista, California and the connections to our cultural devaluation and hatred of women. The violence that occurs in the context of misogyny, racism, transphobia. Our rush to explain away such atrocities as the work of someone “crazy” contributes to the stigmatization of mental health issues. It furthers the myth that mental illness equals and explains violence in our efforts to make sense of the senseless, to try to regain our illusion of control.

It also helps us ignore the larger, systemic, institutionalized issues involved, such as misogyny. As feminist blogger Melissa McEwan tweeted “dismissing violent misogynists as ‘crazy’ is a neat way of saying that violent misogyny is an individual problem, not a cultural one”. When Do We Talk About “Unpleasant” Truths In the Wake of Elliot Rodger’s Destruction? Soraya Chemaly asked, and tweeted:


Breathe and see if you can really take that in, if just for a moment. ALL women live with the threat of male violence. #yesallwomen is happening on Twitter. Have you seen it? Can you look away? A powerful, profound, painful shout back to all the deniers, apologists, and trolls of rape culture and sexism. It is real and raw, the voice of girls and women speaking truth to power: gendered oppression, discrimination, and violence happen. We are all impacted. It is empowering and of course incredibly painful to witness, so be mindful and take good care.

And Dr. Maya Angelou died. Her words and being have impacted me, changed the way I saw the world, since I first read I Know Why the Caged Bird Signs. A survivor of sexual abuse, artist, activist, inspiration. Once silenced by trauma, her voice touched so many.

maI reveled in Laverne Cox on the cover of Time magazine, wondered if this truly is the “tipping point”.  Simultaneously, Jane Doe, a 16-year-old trans girl sits in adult prison with no criminal charges for over 50 days. In An Open Letter to Jane Doe, the 16-year-old Girl Who Smiles & Dreams From Behind Bars, Janet Mock wrote:

Today, I read that you look up to me, and it caught me in an emotional moment, pushing me to think of someone I look up to. Her name was Maya Angelou, and she passed away this week. And the connectivity of your existence, of mine, of hers was not lost on me. Like you, Maya Angelou lived a life full of highs and lows, of struggle and triumph, of abuse and of self-revelation. It was a life of her own creation, a path she blazed for herself in a world not built for her. When there was no blueprint, Maya Angelou created one — a blueprint which became mine.

Connectivity. What threads weave themselves through all these events and issues? Misogyny. Racism. Transphobia. Violence and oppression. Struggle and triumph. Tipping points and simultaneously so much more work to do.  Human rights work. Social justice work. Anti-violence work. We are doing that work. We speak our truths and take up space. We claim our right to this world not made for us. We blaze a path, making it just that bit easier for those who come after us.  And we rise.

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