Wisdom, Attachment, and Love in Trauma Therapy

Beyond Evidence-Based Practice

Susan Pease Banitt

• Editorial: Routledge
• Año: 2018
• ISBN:
  9781351819596
• Edición: 1
• Categoría: Psychologie
• Categoría: Trouble de stress post-traumatique (TSPT)

Wisdom, Attachment, and Love in Trauma Therapy focuses on the creation of the therapist as healing presence rather than technique administrator—in other words, how to be rather than what to do. Trauma survivors need wise therapists who practice with the union of intellect, knowledge, and intuition. Through self-work, therapists can learn to embody healing qualities that foster an appropriate, corrective, and loving experience in treatment that transcends any technique. This book shows how Eastern wisdom teachings and Western psychotherapeutic modalities combine with modern theory to support a knowledgeable, compassionate, and wise therapist who is equipped to help even the most traumatized person heal.

Part I

Wisdom

1 What Makes a Great Therapist?

People will forget what you said, people will forget what you did, but people will never forget how you made them feel.

—Maya Angelou

When I was in my early teens, I met the great family therapist and social worker Virginia Satir. I don’t recall much of what she said. I remember that we were a small group of people in a cozy room with a lady who looked like she was surrounded by a bubble of light. Her unforced smile shone in her eyes as she looked about the room, talking. She spoke of pain and families and healing. I liked how I felt when I was with her; it was a new feeling of safety, of coziness, and something I didn’t have a reference for at the time, wisdom. I felt that while I was in that space with her, everything was OK for the moment. She appeared stable and kind and thoughtful. She spoke of pain in a way that was not painful. Although I was not talking I felt as though I could have said anything to her. The moment became magical without being uncanny. Her intelligence revealed itself as ordinary yet, in its focus, extraordinary. She did not spout theorems or complicated vocabulary. Her communication arose simply and lingered in the atmosphere, instantly understandable. Without realizing it, I decided I wanted to be like her when I grew up, a master therapist.

Many clinicians have never heard of Virginia Satir. She is one of many wise therapists who appear, develop their practice and their theories, and then fade away with time or new thoughts. Some write books, and some do not. These therapists touch dozens of people; some affect thousands. They begin centers, or movements. Many practice quietly in their corner of the world. Maybe they guide a few blooming therapists along the way. If you are fortunate enough to meet a truly wise clinician, you will not easily forget them. Their being carries an essence of healing that is hard to quantify. Their presence transforms you. Once we have met such a person, who transcends the ordinary boundaries of the words counselor, clinician, therapist, we are moved to want to be like them. To watch them work is like watching a great magician, only instead of pulling rabbits out of hats, they pull people out of misery and despair with great skill.

How do we get there from here? You are reading this book right now because you want to know more, to do better, to help your traumatized clients and become a sage clinician. Maybe you are ambitious and competitive, ready to make your mark on the world; maybe you simply have a compassionate heart, or perhaps you have hit ‘the wall’ in your practice, that place where you know you can make a bigger difference with less effort but haven’t figured out how to do so yet, especially with challenging clients. Well, buckle up ’cause Kansas is going bye-bye.

We all start as beginning therapists with the basics:

1. Start on time
2. End on time
3. Don’t make the session be about you
4. Be present

Lather. Rinse. Repeat. Except it is not so easy, is it? To be fully present with another human being, to stay out of our own self-centered, or as the Buddhists would say, self-cherishing, thoughts. This practice is actually quite difficult, like a meditation. Perhaps good therapy is a meditation, and like meditation it may take a lifetime to perfect.

Left/Right Hemispheric Integration

As beginning therapists, we gain skills. Like a good piano player, we learn a piece one hemisphere at a time. In the left-brain side of our work, we digest theories, concepts, techniques; we write about them in school. We read and read. We integrate diagnostic concepts from the Diagnostic and Statistical Manual of Mental Disorders (DSM), whichever version we are on. We observe; we study; we deduce; we assess; we formulate. We treat the patient as an object for our study, and this treatment is necessary for this part of the performance. After all, how can we work inside someone else’s mind when we have only a vague idea of their problems or how a mind even works? Left-brain skills ground our work and give us our professionalism and our licenses. I wouldn’t want to take my car to see someone week after week with them mucking about inside with no idea of what the real problem was. Would you? That would be a tremendous waste of time and money that could be more damaging than helpful. And, we usually have forms we must fill out to show our left-brain competence. So. Many. Forms.

And yet, if our brains were like cars, once we had the diagnostic picture, we would know exactly how to treat it, and the treatment wouldn’t vary much. In that case, why have humans do treatment? Why not computer programs? More reliable, less countertransference! Well, it has been tried. Somewhere, someone is working on an ‘app for that’. Who knows? Maybe they will be successful. But I don’t think so. There is another side to the brain!¹

A pianist’s right hand has to operate absolutely independent of the left hand. This, in itself, is a minor miracle when you think about it. Sometimes when I present on this material, I show a clip of Martha Argerich playing a Bach partita on the piano.² When you play with only one hand, you get half the piece and a much less interesting listening experience, an incomplete composition. To play a Bach partita, two hands are playing different melodies that weave and clash, integrate and spring apart. Playing at this level requires an intense degree of neural integration only developed through hours and hours of painstaking practice, practice that is often as frustrating as it is rewarding.

The same principle that makes for a great pianist applies to being a great therapist. We are more than a collection of thoughts and theories. Great therapists work with their intuition, pattern recognition, and their own feelings (countertransference), sorting through decision trees and matching their observations with moment-by-moment choices of how to interact with a client. These choices include where to look, how to sit, how to breathe, when to stay silent, when to speak, how to modulate the voice, where to put emphasis, and when to articulate an observation versus when to ask a question and wait, how to use our facial expressions, and much more. Sure, we know many theories, many techniques, but how do we know when to use them? The neurological complexity of our task cannot be overstated. Good therapy is called an art and a science. We fuse our left-brain knowledge with gut feelings, the heart of compassion, and the ineffable intuitive knowing of the right brain. We have to practice each hand separately, sussing out both theories and our intuitive connection to our clients, and learn the music of healing before that beautiful moment when we can skillfully play our music with both hands. It may take many years of practice before we produce a masterpiece. This complicated process is why checklist therapy will never work for our most difficult cases. Procedures and checklists are tools, but they are not the art. They are dumb instruments that need to be in the hand of maestros. We are kidding ourselves if we think we can solve the problems of issues like developmental trauma with a prescribed protocol. In fact, my practice and the practices of many of my colleagues are filled with failures from such one-size-fits-all evidence-based approaches.

One more consideration is necessary to complete the musical analogy—a pianist can go out and find a lovely instrument on which to play their beautiful music. The instrument we play in therapy is our own being, our own brain and gut, our own nervous system. Like actors, we must first develop our bodily instrument before we may play well upon it. We cannot commission someone to build us a beautiful, wise, and empathic brain; we have to build it ourselves. This awareness separates mediocre therapists from truly wise ones. Our work will only be as good as our limbic instrument born of our own self and character development. This truth should be self-evident, but in case it is not, let us do a thought experiment. I could give two therapists the exact same protocol—maybe a CBT one or an exposure therapy one, or even a mindfulness script. Now imagine how the protocol is executed. One therapist has come from a weekend retreat, is blissfully centered, relaxed, and happy with their life. The other therapist has an anger problem and constantly gets annoyed with the people in their life; maybe they had a road rage incident on the way to work. Both clinicians have a great deal of self-control and education. But whom would you rather sit with if you were feeling vulnerable? How would the protocols be affected by the mien of the therapist? Scripts are easy to teach, but only modestly effective without a strong therapeutic alliance. Over the last couple of decades, there have been several studies and meta-analyses that consistently show the therapeutic relationship as superseding theoretical orientation or technique in the importance of a successful therapy. In this 2015 study, where a CBT protocol was used with psychotic patients, the authors concluded the following:

The patients’ perception of the therapist as empathic, genuine, accepting, competent and convincing is associated with therapeutic alliance in CBTp. Perceived therapist genuineness and competence are the most relevant predictors of patient-rated therapeutic alliance. Training and supervision should focus on increasing basic therapist qualities.

(Jung, Wiesjahn, Rief, & Lincoln, 2015)

Doing therapy by protocol is relatively simple but is only really effective if the therapist takes on the task of being the therapy by their very essence and presence.

In the intermediate stage of clinical work, we have mastered many theories and techniques. We have worked hard to get to know ourselves. Perhaps we have a good grasp of our own countertransference to our patients’ transference. We have several years of supervision, and hopefully several years of our own therapy under our belt. We have a modicum of competence.

Let’s look at competence in the model of the four stages of competence (Adams, 2017):

1. Unconscious incompetence—the ordinary person as counselor may or may not give great advice but has no knowledge of the pitfalls of relationships or deeper structures in the psyche. This person has little to no insight into their own mind. Pre-beginner stage.
2. Conscious incompetence—ideally this stage emerges during graduate school or during licensure supervision. It may manifest whenever a therapist works with a new population at any point in one’s career. It is a very uncomfortable stage in which people either feel like quitting or become invigorated by the challenge (or both). Beginner stage.
3. Conscious competence—the intermediate stage where one has an adequate set of tools and a good idea when and how to apply them. This stage requires a lot of conscious focus, integration, and practice. It can go on for years, and many clinicians never really transcend this stage due to their own unhealed issues, fragmentation, or lack of interest in learning how to ‘play with both hands’.
4. Unconscious competence—the clinician has now fully integrated their knowledge with their way of being. Like a trained dancer, any misstep becomes part of the dance and the audience is unaware of a problem in the choreography, because really at this stage of competence, there are no problems that cannot be turned towards healing. The two hands play together consistently, and it can feel like magic. Instead of conducting therapy, therapy is conducting us, and there is a quality of flow and bliss to the work.

An advanced clinician has not only mastered the fourth stage of competence (understanding that mastery is less of a destination and more of a process), but has also incorporated their work into their entire being. Like my experience with Virginia Satir, wisdom radiates in the therapy regardless of the therapist’s specific words or actions. The more challenging our clients’ issues, the more necessary it is to develop these qualities in oneself if we want to be successful and bring the maximum amount of healing ability to the therapy.

Being vs. Doing

When I assembled my first talk on wisdom and advanced practice for trauma clients, I found it difficult to find overarching models of wisdom in the West that were not religious. In fact, if you Google the words ‘Western Wisdom’, the top finding is a website of sayings from the Old West, like “Polishing your pants on saddle leather don’t make you a rider” and “Don’t name a cow you plan to eat.” Of course, the West does have its philosophers and thinkers as well as some truly great therapists. But to get to the essence of wisdom teachings for therapists and healers, I found it helpful to turn to the teachings of the East: Hinduism, Buddhism, Taoism.³ These cultures are so ancient that the mind boggles trying to comprehend the longevity of these awarenesses and teachings. What really separates the East from the West in terms of wisdom, philosophy, and even theology are the concepts of Being vs. Doing.

My second-year supervisor had his own mantra for me, “Don’t just do something, sit there.” He scrawled this mantra on my process recordings and repeated it on a regular basis in supervision. Like any young person in America, I was a doer. We are taught to ‘do’ in school from the time we hit kindergarten until we graduate our professional programs. Schools do not really teach us how to ‘be’. Even the focus in therapy has shifted from more of a ‘being’ modality, such as psychoanalysis, to ‘doing’ modalities, i.e., 6- to 8-week evidence-based protocols that ‘git ’er done’. Problem is, evidence-based protocols are generally based in research that only looks at effects 3 months, 6 months, sometimes 12 months out of the study. It is not cost effective to conduct studies over long periods of time, and academic departments need to ‘publish or perish’. I am not opposed to peer-reviewed research; studies can be helpful with some caveats. Studies are limited in their usefulness and generalizability, especially for folks in private practice settings who may be seeing highly complex cases over long periods of time.

Let’s look at some of the differences between evidence-based (doing) vs. wisdom-based (being) practices. Evidence-based practices are very recent, whereas wisdom-based practices are ancient. In Chinese medicine, a treatment is not considered vetted until it has been studied for about 200 years—a vastly different timescale than our peer-reviewed studies, most of which do not look at effects past one year! The idea that the practitioner’s quality of being is an essential part of healing the patient is thousands of years old. Ayurvedic practitioners from India, Chinese medicine practitioners, and medicine people from indigenous tribes all had to qualify themselves through their character, calmness, and steadiness of mind over a long period of time before they were accepted as students or apprentices. In addition, there needed to be a level of moral or spiritual attainment evident to be accepted into training. By contrast, college student admission often favors the ‘go-getter’ and prefers accomplishments to insight, morality, or wisdom. Some of the wisest students I’ve met take fewer AP classes and do fewer extracurricular activities to maintain their mental health and peace of mind. They do not get into the ‘top’ schools. The morality (and mental health) of the student is often assumed in psychology programs. When problems arise with a clinical student’s behavior, they are often dealt with retroactively rather than proactively. With a financial need to accept and keep students, some programs do not have the luxury of weeding out poor practitioners even if they want to.

Modern research studies look for relatively short-term changes in small measurable outcomes, and it is best if those changes happen rapidly. Western, and especia...