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So my note was read and we talked aboit it a bit. She appologized mostly and said that she didnt mean to communicate what I got from that session..... I accept that even though Im somewhat still confused about some of what she said and I brought those up and she just appologized again so... okay.... LOL. I believe her but I still greatly feel that she is really really showing her status as a 'student' and as aresult this is why we had this sort of problem...

Anyways, what we are doing is considered a type of trauma work right now and I'm not familiar with it.... but I did some reading online and found a very good article that actually talks about some of what we are working on... it's the following.. I will post it here even though it could go into the research/article section..... the part most applicable to our current theraputic plan is the paragraph concerning THerapies Addressing SHame.....

If anyone takes the time to read this and that.. let me know your thoughts, expereinces, etc if you want to share...

PSYCHOTHERAPY PAPERS
http://bjp.rcpsych.org/cgi/content/full/177/2/144#top
Psychological therapies for post-traumatic stress disorder{dagger}
GWEN ADSHEAD, MRCPsych

Traumatic Stress Clinic, 73 Charlotte Street, London WIP ILB, or Psychotherapy Department, Broadmoor Hospital, Crowthorne, Berkshire RG45 7EG

Declaration of interest None.

{dagger} See editorial, pp. 93-94, this issue. Back

ABSTRACT:
Background After exposure to traumatic stressors, a subgroup of survivors (20-30%) will develop post-traumatic stress disorder (PTSD).

Aims Since the incidence and prevalence rates for PTSD in the community are significant, it is important that general practitioners and psychiatrists be familiar with possible therapeutic options. In this review we shall look at the published evidence about the effectiveness of psychological treatments for PTSD.

Method The psychopathological mechanisms involved in PTSD are discussed. Studies of the effectiveness of different psychological therapies are reviewed.

Results The review suggests that persistent fear or shame reactions are key aspects of PTSD. Evidence from systematic reviews suggests that psychotherapeutic treatments are effective in the therapy of reactions based on fear, and may increase the effectiveness of pharmacological therapy. There is less systematic evidence for the efficacy of interventions for symptoms based on shame.

Conclusions Although a proportion of patients with complex or chronic PTSD may require specialist interventions, most patients can be treated effectively by a general psychiatric service which can offer both pharmacological and psychological interventions.

INTRODUCTION

It is clear that traumatic events, especially those which induce significant feelings of fear and helplessness, can cause psychological disorders in those who survive them. The most common post-traumatic disorders are depression and substance misuse; other possible disorders include acute stress reactions, anxiety states such as phobic and panic disorders, and personality change after trauma. It is unusual for any one post-traumatic disorder to occur in isolation; comorbidity is the norm.

Although one of the less common types of post-traumatic psychopathology, post-traumatic stress disorder (PTSD) has received considerable clinical and research attention over the past 18 years. PTSD occurs in 20-30% of people who are exposed to traumatic stressors; it is rare for patients to present with ‘pure’ PTSD.

It is not possible in a brief review to examine the indications for, or efficacy of, psychological therapies for all the post-traumatic disorders. For most disorders, standard therapeutic interventions are indicated; and therefore this review will be confined to psychological therapies for PTSD in adults. The treatment of PTSD in children is a specialist area which will not be dealt with here. Although psycho-pharmacological treatments are outside the remit of this review, they are often combined with psychological interventions, and play an important role in the effective treatment of PTSD. Recent research demonstrates that PTSD is a neuro-physiological disorder, with demonstrable effects on the hypothalamic—pituitary axis, hippocampal volume, and endogenous opioid function.

ASSESSMENT FOR PSYCHOLOGICAL THERAPY OF PTSD

Clinicians are as likely to see people with PTSD as they are to see patients with schizophrenia. The prevalence of PTSD is 1% in the general (US) population; lifetime prevalence rates are reported to be up to 9.2% (Helzer et al, 1987; Kessler et al, 1995). The prevalence is higher in those exposed to traumatic events; the experience of interpersonal violence increases the prevalence up to 20-30%. Treatment planning entails a detailed assessment addressing the key features of PTSD.

The entry criterion (Criterion A) for the diagnosis of PTSD (DSM-IV; American Psychiatric Association, 1994) defines traumatic stressors (as opposed to ordinarily unpleasant stressors) as the witnessing of, or experiencing, threat to life or severe injury to the self, or to a significant other. This objective aspect of Criterion A reflects the established finding that threat to life is a potent predictor of PTSD, which distinguishes PTSD from other types of stress-induced illness. The other specifically traumatic aspect of stressors is the subjective experience of "intense fear and helplessness". The experience of a life-threatening stressor, and the experience of intense fear and/or helplessness, are necessary for a diagnosis of PTSD.

The objective and subjective criteria for PTSD neatly reflect current thinking about the aetiology of PTSD. One the one hand, the risk of developing PTSD is directly related to exposure to traumatic stressors; that is, the more exposure, the higher the risk of developing PTSD. The duration of the traumatic event is important as an indicator of the degree of exposure, and the assessor needs to enquire about the ‘fear’ aspect of the traumatic experience, especially the perception of threat to life.

On the other hand, there is ample evidence that personality structure and experience (such as neuroticism or childhood adversity) in the period before the traumatic event also influence the risk of developing PTSD. The personal history of the individual patient needs to be examined for information about previous vulnerability factors (such as early fear experiences and insecure attachments) and resilience factors (such as self-esteem). Early fear experiences may be significant in terms of later capacity to manage threat (Dodge et al, 1997). Individuals may have high degrees of resilience even where there has been early and severe childhood adversity.

When the trauma occurred is therapeutically relevant. If the traumatic event occurred between 4 and 8 weeks before the interview, then the patient is likely to be experiencing severe symptoms. If many dissociative symptoms are present, these may constitute an acute stress disorder (American Psychiatric Association, 1994). Although such disorders often resolve spontaneously over the following 4-6 weeks, patients may benefit from a shortterm intervention (see below). Acute stress disorder is a risk factor for the development of later PTSD.

The nature of the patient's traumatic experience is also important to assess, because some types of trauma are more likely than others to provoke PTSD. Highrisk stressors include those which involve grotesque sensory images, interpersonal violence (especially sexual assault) and chronic fear and helplessness.

Finally, it is important to assess the patient's world view (Weltanschauung) before the trauma occurred. Individuals at risk of developing PTSD include those who tend to have an ‘all or nothing’ view of events and their part in them. Cultural stereotypes (especially about gender role) are highly relevant (Turner et al, 1996). Resilient individuals tend to see themselves as neither omnipotent nor helpless in the face of stress; and they are not ashamed to seek help and use what is offered. In contrast, vulnerable individuals tend to see care-seeking as shameful and anxiety-inducing.

TREATMENT PLANNING

The conscious and/or unconscious neurophysiological sequelae of experiencing traumatic stressors are overlaid with the psychological meaning ascribed to the experience by the individual, and his or her conscious and unconscious beliefs about him or herself and the world. The sudden and acute experience of terror, and one's own mortality, has an impact which is both physiological and psychological. It is therefore essential to consider both these aspects in treatment planning.

Most explanatory models of PTSD have argued that it represents a failure to process the experience of fear; reflecting in turn either a previous vulnerability to fear, or exposure to extremes of fear (Foa & Kozak, 1986). However, some patients suffer more from other affects, especially sadness, guilt and shame (Andrews, 1998). For such individuals, it seems likely that something about the traumatic experience affected their sense of themselves: the way they think about themselves, and about others in relationships with them. Their symptoms seem to express less about the shattering of external security by fear, and more about a fragmentation of an inner sense of security.

These different types of affective reactions have implications for psychological therapy. Patients with principally fear-based reactions will need therapies which address the management of fear and anxiety. Patients with shame-based reactions will need a psychological therapy which focuses on cognitive representations of the self, and relationships with others. Previous experiences of fear and safety will be relevant to both types of patients, especially in terms of forming a therapeutic alliance. Both shame and fear reactions can coexist in the same patient.

REVIEW OF PSYCHOLOGICAL THERAPIES FOR PTSD: META-ANALYSES

This paper is not a comprehensive systematic review, although we searched the literature from the past 5 years both by computer and ‘by hand’. Two recent meta-analyses have studied the psychological treatment of PTSD (Sherman, 1998; van Etten & Taylor, 1998). Studies using psychodynamic methods were included in both analyses. Psychological therapies appear to be more effective than psychotropic medication (van Etten & Taylor, 1998), although patients treated with both improved more than did controls. Sherman found significant effects for all psychological therapies, particularly for behavioural therapy, but found no support for one single rationale for therapy. His positive view contrasts with that of Shalev et al (1996), who found less significant effects for psychological therapies. However, Shalev et al included several studies that were open-ended, and where the therapy programme was less structured.

THERAPIES ADDRESSING FEAR

Most of the therapies described in the meta-analyses include behavioural and cognitive strategies for managing fear by exposure to the feared stimulus, whether in imagination or in the external world. Exposure therapy seems to be effective for many patients, including combat veterans and victims of interpersonal violence. Exposure therapy usually takes the form of systematic desensitisation, in which the patient is gradually encouraged to reduce avoidance of the feared image or memory. Exposure may be imaginary or live (Richards et al, 1994), and utilises trauma-based imagery generated by the patient in the form of remembered images, or a written script.

Exposure therapies can also be combined with cognitive processing interventions (e.g. Resick & Schnicke, 1993), stress inoculation and relaxation techniques, and anxiety management training (Rothbaum & Foa, 1996). Both exposure and cognitive restructuring techniques seem to be effective, and are more effective than relaxation alone (Marks et al, 1998). Another form of exposure therapy employs cognitive reprocessing combined with saccadic eye-movements (eye-movement desensitisation and reprocessing, EMDR). Recent studies suggest that this strategy can be effective with combat veterans, and survivors of child abuse and disasters.

Most of the studies of fear-based therapies report a decrease in ‘target’ symptoms of PTSD, namely avoidance and intrusion phenomena such as flashbacks. Fear-based therapies are probably most effective in patients: who describe high levels of intrusive phenomena; who are not severely depressed or misusing substances; in whom the traumatic experience was a relatively discrete episode in their lives; who do not have extensive histories of trauma previous to the index event; and who had reasonably good psychological health before the index event.

The traumatic event need not be recent for fear-based therapies to be effective, as is demonstrated by Case 1.

Case 1. Mrs Jenkins

Several years before presentation, Mrs Jenkins had been traumatically bereaved while on holiday abroad. Her husband was killed by a bomb which exploded outside their hotel during a period of civil unrest. Mrs Jenkins was able to give an account of what had happened (hearing the noise, coming out and finding the body), but it was lacking in detail. She was drinking heavily, socially withdrawn, and sensitive to loud noises in the street; fireworks night was especially difficult. After some initial work to establish the therapeutic alliance, exposure work was planned. Mrs Jenkins agreed to describe her experiences in as much detail as possible, over a number of sessions. She was also encouraged to write an account of her experience between sessions. At the third session, Mrs Jenkins recalled afresh seeing the "blueness" of her husband's eyes as he lay dying. This memory was acutely distressing to recall, but significant symptomatic relief followed this session. Subsequent sessions were easier, and at the end of six sessions, Mrs Jenkins was clinically improved and ready to be discharged.

Most therapy now takes place in out-patient settings. It is relatively short-term (8-15 sessions), and patients are encouraged to do ‘homework’ between sessions. The session content may follow a set order according to established protocols. Although cognitive techniques do address the question of dysfunctional beliefs and self-schemata, most of the emphasis of these therapies is on the minimisation of avoidance behaviour, and experience of avoided fear, with subsequent reduction of anxiety and increase in confidence.

Much of the earliest work in this area was done with combat veterans, and in in-patient settings. Typically such work included group psychotherapy and behavioural interventions. In a review of such interventions, Read Johnson (1997) suggests that the in-patient programmes were ineffective for PTSD. However, a related discussion paper points out that nearly half of the subjects studied had histories of childhood trauma, and many had experienced significant traumatic experience after combat. Short-term or unimodal therapeutic strategies are unlikely to be successful with patients who need to make sense of both fear and shame experiences, and who are having to cope with many other stressors simultaneously.

THERAPIES ADDRESSING SHAME*************

The experience of shame is closely linked to the feelings of depression, guilt and humiliation. Shame and guilt can be difficult to distinguish; although both involve negative self-evaluation, feelings of guilt may relate more to behaviour, whereas shame may reflect low self-esteem and self-criticism (Andrews, 1998). Patients with posttraumatic shame experiences tend to describe less intrusion and re-experiencing phenomena associated with PTSD. Instead, they describe experiences of ruminating on what went wrong, how they failed, their sense of hopelessness and helplessness, and other self-directed cognitions such as guilt. The painful thoughts and feelings seem to be less to do with fear of death, and more to do with the loss of an inner sense of self-confidence and esteem.

This type of post-traumatic presentation, which particularly affects the patient's concept of self, has also been called ‘complex PTSD’ (Herman, 1992). Herman describes the following characteristics of complex PTSD:

1. experience of prolonged abusive coercion;
2. alterations in affect regulation;
3. alterations in consciousness, especially depersonalisation and de-realisation states;
4. alterations in self-perception;
5. alterations in perception of trauma/perpetrator;
6. alterations in relations with others; and
7. alterations in systems of meaning.

In DSM-IV field trials, Roth et al (1997) found that complex PTSD is associated with the experience of prolonged exposure to trauma (i.e. over days, months or years), and first exposure at an early age. Complex PTSD is also associated with prolonged interpersonal victimisation, such as battering by a partner, torture or prisoner-of-war experiences, and child abuse.

An atypical case makes a good example (and also makes the point that complex PTSD is not only related to child abuse or torture).

Case 2. Mr Smith

Mr Smith was assaulted from behind by a man whom he could not see, and who was unknown to him. He was repeatedly beaten about the head, and the assault only ended when the man ran off. Mr Smith was powerless to defend himself against this man. He felt helpless and humiliated. This experience contrasted with his previous views about himself as a powerful man, who could handle anything and was the leader and provider for his family.

Mr Smith's self identity was bound up with being strong and powerful. Thus, at one level he identifies strongly with his assailant, shares his values and wants to be like him. He despises his own experience of being assaulted and helpless. On the other hand, to value his victimised self, he must make a split from his assailant in his mind, and let that identification go. He has to lose and mourn a real part of himself. He alternates between feeling ashamed and depressed.

It is perhaps noteworthy that Mr Smith's difficulties developed after an attack which lasted some 20 minutes. One can only speculate about the damage done to the sense of self, if attacks like this go on for many years. Although the symptoms of complex PTSD resemble depressive symptoms, the alteration in the sense of self is crucial to personal functioning. It may be that the concept of complex PTSD overlaps with the concept of "enduring personality change after trauma", as described in ICD-10 (World Health Organization, 1992).

The aim of shame-based therapies, especially in cases of complex PTSD, is to try to help the patient to restore some sense of meaning in terms of their own sense of self, and to move from the traumatic sense of self to a narrative (and developing) sense of self (Lindy, 1996). Sessions focus on beliefs about the self and others and on the experience of painful feelings such as shame and rage. The awareness and expression of the patient's anger are important aspects of the therapeutic process; for many patients, a continuing sense of shame relates to a profound and pervasive anger. In such cases, there may be less need to go over, or rehearse, details of the traumatic experience: indeed, such a process may be counter-productive because it can increase distress and shame in someone who is already not coping well with such feelings. In general, the patient is not avoiding thinking about the experience, but rather is ruminating about it. Exposure therapy (including detailed rehearsal or exposure to traumatic memory) is therefore unlikely to be helpful in such cases, because it dismantles defences against psychological distress. Instead, the therapeutic emphasis is on support for coping strategies, and the shoring-up of defences (Embry, 1990). The therapeutic aim is to generate with the patient an environment in which feelings of shame (and sometimes of accompanying rage) can be safely explored. Although it is vital for both fear-based and shame-based therapies that the therapeutic environment is safe (Turner et al, 1996), this aspect of treatment is more pronounced for patients with complex PTSD because they lack inner capacities for self-soothing, at least initially. The therapist may have to help the patient to learn to soothe themself, and teach them how to contain arousal; adjunctive medication can be useful here.

Difference between fear-based and shame-based therapies
Unlike fear-based therapies, in a shame-based therapy the relationship between the patient and the therapist is likely to be itself a major part of the therapeutic process. This is because, for many patients, the traumatic events took place in the context of an ongoing relationship; the relationship was the trauma. Therefore, the patient's thoughts and fantasies about the therapist (transference) and the therapist's thoughts and fantasies about the patient (counter-transference) will become part of the clinical effort. Patients may find it hard to trust the therapist, and the establishment of a therapeutic alliance may take months rather than weeks. Alternatively, patients may become intensely dependent on their therapist, and seek to hand over to them ali responsibility for their health.

The therapist, too may have responses to the patient which need consideration. In particular, the therapist needs to guard against the following countertransferential reactions:

1. Rejection of the patient ("they're too awful") - such a feeling may reflect the clinician's own reluctance to think about terrible experiences.
2. Certainty for the patient ("let me tell you what happened to you") - this may represent a way for the therapist to control anxiety-provoking material. Other types of control reaction in the therapist include giving advice or instructions to the patient.
3. Exploitation of the patient's compliance or dependence ("you don't mind if I do this, do you?").

A potent way to reduce psychological shame is to decrease the sense of alienation and isolation that it brings. It may be for this reason that group therapies have been widely used in post-traumatic psychotherapy (Turner et al, 1996). These can be short-term or long-term; exclusively focused on a traumatic event or not. Many patients have found that the development of self-help groups is effective not only in reducing shame but also in increasing a sense of self-empowerment, challenging passivity and helplessness. The main role of the therapist (where there is one) will be to establish safety in the group, with particular attention to group boundaries and setting limits to behaviour.

Acute readers may have noticed a similarity between the psychotherapy of complex PTSD and the psychotherapeutic treatment of personality disorders. This is unsurprising, given that early childhood trauma is an established risk factor for the development of later personality disorder. Clinicians working with personality-disordered patients may find some useful information in the literature on the psychodynamic treatment of PTSD (Embry, 1990; Lindy, 1996).

EARLY AND BRIEF INTERVENTIONS

Although it was hoped that early interventions such as debriefing might prevent the development of PTSD, there is little evidence that this is so (Wessely et al, 1997; Bolwig, 1998). In fact, there is some reason to think that some vulnerable individuals may experience more symptoms as a result of a debriefing intervention (Bisson et al, 1997). Such data suggest that early interventions may only be of value to some individuals, and that such interventions need to be targeted. When supportive interventions are offered to survivors of traumatic events, most people do report finding them helpful, so there is still research to be done on what this ‘help’ might be. There are important implications for public health and civil litigation here.

CLINICAL IMPLICATIONS

CLINICAL IMPLICATIONS

* PTSD can be treated effectively with psychological interventions.
* Psychological interventions are more effective than pharmacological interventions, although both are better than placebo.
* Fear-based reactions and shame-based reactions may need different types of psychological therapy.

LIMITATIONS

* There have been far fewer studies of the efficacy of psychological therapies for complex PTSD, or shame-based reactions.
* There may be other psychopathological variables active, apart from shame and fear.
* Most treatment studies are made on highly selected samples.

ACKNOWLEDGMENTS
I am grateful to my colleagues at the Traumatic Stress Clinic, Middlesex Hospital, and to Dr Gill Mezey and Dr Bernice Andrews for their help with the writing of this paper. I am also grateful for the comments of two anonymous reviewers, and for the secretarial assistance of Anne Kavanagh.

To preserve anonymity, the cases described are composites of real cases and cannot be identified with any individual.

REFERENCES
American Psychiatric Association (1994) Diagnostic and Statistical Manual of Mental Disorders (4th edn) (DSM-IV). Washington, DC: APA.

Andrews, B. (1998) Shame and childhood abuse. In Shame: Interpersonal Behaviour, Psychopathology and Culture (eds P. Gilbert & B. Andrews), pp. 176-190. Oxford: Oxford University Press.

Bisson, J. I., Jenkins, P. L., Alexander, J., et al (1997) Randomised controlled trial of psychological debriefing for victims of acute burn trauma. British Journal of Psychiatry, 171, 78-81.[Abstract/Free Full Text]

Bolwig, T. (1998) Debriefing after psychological trauma. Acta Psychiatrica Scandinavica, 98, 169-170.[Medline]

Dodge, K. A., Pettit, G. & Bates, J. E. (1997) How experience of early physical abuse leads children to become chronically aggressive. In Developmental Perspectives on Trauma: Theory, Research and Intervention (eds D. Cicchetti & S. Toth), pp. 263-288. Rochester, NY: University of Rochester Press.

Embry, C. (1990) Psychotherapeutic interventions in chronic post-traumatic stress disorder. In Posttraumatic Stress Disorder: Etiology, Phenomenology and Treatment (eds M. Wolf & A. Mosnaim), pp. 226-237. Washington, DC: American Psychiatric Press.

Foa, E. & Kozak, M. (1986) Emotional processing of fear: exposure to corrective information. Psychological Bulletin, 99, 20-35.[CrossRef][Medline]

Helzer, J. E., Robins, L. N. & McEvoy, L. (1987) Post-traumatic stress disorder in the general population. New England Journal of Medicine, 317, 1630-1634.[Abstract]

Herman, J. L. (1992) Trauma and Recovery. New York: Basic Books.

Kessler, R. C., Sonnega, A., Bromet, E., et al (1995) Post-traumatic stress disorder in the National Co-Morbidity Survey. Archives of General Psychiatry, 52, 1048-1060.[Abstract]

Lindy, J. (1996) Psychoanalytic psychotherapy of post-traumatic stress disorder: the nature of the therapeutic relationship. In Traumatic Stress: The Effects of Overwhelming Experience on Mind, Body and Society (eds B. van der Kolk, A. McFarlane & L. Weisaeth), pp. 525-536. New York: Guilford.

Marks, I., Lovell, K., Noshirvani, H., et al (1998) Treatment of post-traumatic stress disorder by exposure and/or cognitive restructuring. Archives of General Psychiatry, 55, 317-325.[Abstract/Free Full Text]

Read Johnson, D. (1997) Introduction: inside the specialised inpatient PTSD units of the Department of Veterans Affairs. Journal of Traumatic Stress, 10, 357-360.[CrossRef]

Resick, P. A. & Schnicke, M. K. (1993) Cognitive Processing Therapy for Rape Victims: A Treatment Manual. London: Sage.

Richards, D., Lovell, K. & Marks, I. (1994) Post-traumatic stress disorder: Evaluation of a behavioural treatment programme. Journal of Traumatic Stress, 7, 669-680.[CrossRef][Medline]

Roth, S., Newman, E., Pelcovitz, D., et al (1997) Complex PTSD in victims exposed to sexual and physical abuse: results from the DSM-IV field trial for Post-traumatic Stress Disorder. Journal of Traumatic Stress, 10, 539-556.[CrossRef][Medline]

Rothbaum, B. O. & Foa, E. (1996) Cognitive-behavioural therapy for posttraumatic stress disorder. In Traumatic Stress: The Effects of Overwhelming Experience on Mind, Body and Society (eds B. van der Kolk, A. McFarlane & L. Weisaeth), pp. 491-509. New York: Guilford.

Shalev, A., Bonne, O. & Eth, S. (1996) Treatment of post-traumatic stress disorder: a review. Psychosomatic Medicine, 58, 165-182.[Abstract/Free Full Text]

Sherman, J. J. (1998) Effects of psychotherapeutic treatments for PTSD: a meta-analysis of controlled trials. Journal of Traumatic Stress, 11, 413-436.[CrossRef][Medline]

Turner, S., McFarlane, A. & van der Kolk, B. (1996) The therapeutic environment and new explorations in the treatment of post-traumatic stress disorder. In Traumatic Stress: The Effects of Overwhelming Experience on Mind, Body and Society (eds B. van der Kolk, A. McFarlane & L. Weisaeth), pp. 537-558. New York: Guilford.

van Etten, M. L. & Taylor, S. (1998) Comparative efficacy of treatment for post-traumatic stress disorder: a meta analysis. Clinical Psychology & Psychotherapy, 5, 126-144.

Wessely, S., Rose, S. & Bisson, J. (1997) A systematic review of brief psychological interventions ("debriefing") for the treatment of trauma-related symptoms and the prevention of post-traumatic stress disorder. Cochrane Review 25/11/97. Oxford: Update Software.

World Health Organization (1992) The ICD-10 Classification of Mental and Behavioural Disorders. Geneva: WHO.

Received for publication December 8, 1998. Revision received November 30, 1999. Accepted for publication December 7, 1999.
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Butterfly Warrior,
The part about shame based treatments could be a description of me. I experienced childhood sexual abuse from around the age of 4 until I was 9 when my parents split up (at least that's what I've managed to remember so far) complicated by the fact that my mother was pretty emotionally absent having had a pretty sucky childhood herself. With my first therapist I did alot of work around dealing with remembering and working through the trauma, with my therapist now I'm working through the shame. Thanks for this article by the way, I've been fighting the feeling that somehow all those years of therapy with my first therapist were useless because I've been doing such intense work with my present T (as in, dear God, how much therapy can one woman need?) but this article actually provides an explanation. My work with my T has definitely centered around our relationship, as a matter of fact our work together took off when I talked to him about feeling attracted to him. I can't begin to describe to you the level of insecurity this relationship has revealed to me and my ambivalence about getting close to anyone. My T (who is really amazing at his work) has esssentially been holding still for 9 months and reassuring me he's not going anywhere including let me call him inbetween sessions just to make sure he's still there. I've finally started to feel somewhat secure with him which made things better and made things worse. I figured out at a very young age I wasn't supposed to have feelings or needs or people would leave, so guess what? I buried them pretty deep. Most of what is coming out is grief and anger. The anger is especially difficult because my father raged alot and was physically abusive as well so getting angry was really dangerous and makes me feel like I'm going to turn into him. Letting the anger out has also been scary because of the intensity of hatred I felt and some of the things I've had to acknowledge I wanted to do. There is an incredibly deep sense of shame attached to them, so deep that sometimes wanting to die seems like the only solution. My T is spending alot of time with me explaining, over and over again, that these feelings are normal, that I haven't acted on them, and I have a right to feel them. Its painstaking and slow but its working. But the only way to do it has been to allow my T to hold me together because often the emotions get so intense that I feel like "I" just dissappears. Sorry to go on so long, but I'm right in the middle of it and this just really resonanted with me. Hope some of this helps. Below is a poem I wrote recently dealing with these feelings of shame and terror.

Inexorable black tide
Fear rises, breathe quickens
The pursuit of terror begins
I don't know what happens if I get caught
But I do know I don't want to find out
Thinking becomes almost impossible
No one else seems to feel this
How not, when the very air screams?
Behind the fear comes searing pain
The knowing of an absolute worthlessness
The only good is to remove the lesion that I am
I struggle to retain this is not real
Not the whole truth
Not the whole meaning
But I am weary and long to give up
But some small defiant ember
refuses to extinguish
I will not believe what I have been told
over and over and over
I will not let the end be written here
I will not abide in isolation
Thought I do not believe what I hear yet
still I will choose to trust
I will wear this mask until I have a face

If you're reading this, thanks for wading through all of this. Eeker

BTW, below are some links to a few articles I found really helpful:

http://www.healingresources.info/trauma_attachment_stress_disorders.htm

http://www.menningerclinic.com/resources/coping_trauma05.htm
http://www.integrativetherapy.com/en/articles.php?id=30
AG- I have shivers in my soul and a deep longing to hug you. Cyber hugs is the best if you would like them. ((((((((((AG))))))))).

I'm honored by what you have shared here!!! I never knew if I was going to get a response at all and thought.."Great, I posted way too much and whatever..." lol... but in the end, I was wrong.. for you it ressonated and in that, there is much healing to me in that knowledge....

quote:
I've been fighting the feeling that somehow all those years of therapy with my first therapist were useless because I've been doing such intense work with my present T (as in, dear God, how much therapy can one woman need?)


I too have felt this way with my past therapists!! I was willing to share this with my current one and something she said was useful and that was the fact that tfirst off.... how mnuch therapy.. well it took a long time to cause someone this much hurt and pain and it takes a long time to undue. In addition.... all of the time before hasn't been wasted at all because that was the period for which you needed to figure out what was going on and learning to even deal with that part of it. Without that part, it's unlikely you would have the current work.

For me, my first therapist and I did a ton of work and I thoight she was irreplacable. She added a lot to me in terms of the cultural aspects of my trauma story and in addition, we did some trauma work though she didnt recognize that I stgill had PTSD> Yet I wouldnt have graduated from college had it not been for her. Than I got Holly and we REALLY hit hard on trauma work in ways that were not even CLOSE to anything I had EVER expereinced. It was quite upsetting... LOL... but it was amazing yet she was right about something... had I not had Jeanne to learn to trust and even test the waters of letting her know my stories.... I probably wouldn't have been willing to go where I did with Holly. And now.... it's like I'm the one telling my therapist.. Um I need More... Do so mething... tell me more.. Help me see.... its like Im an eager participant in SUCKY trauma work and never would I have ever thought I would volunterily WANT To try and deal with all of the CRAPPPPPP! l

quote:
I talked to him about feeling attracted to him. I can't begin to describe to you the level of insecurity this relationship has revealed to me and my ambivalence about getting close to anyone.
... the ever so common expereince of transference. I have never gone through that but I hear its common and is very much tied to trauma... It's so brave and amazing that you were willing to let him know what was going on and he has continued to be there and show you a positive non abusive healing example, side of humanity....

quote:
Most of what is coming out is grief and anger.
How has this been??? I find it so hard to expereince anger. Anger means pain and its so difficult. It must be stressful yet relieving in a way to be able to even express and have these emotions/feelings. TO be able to feel and grieve over what has gone on and realize that you aren't your dad....

I know my theraoist has talked a lot abotu Core Beliefs.. those things that often come in childhood that we think deeply about ourselves and often effect what we do.... I think all of this time you felt like you might become your dad or what these different emotions might feel or be and now to be able to express them must be freeing. I havent gotten to this point yet. I have a lotg of emotion and feeling for others but for me, it's still a struggle. I feel much confusion still and part of it is the discountnuity of my caqre. I think if i Had been able to stick with a therapist like Holly, I would do much better than having such disruption....

quote:
to allow my T to hold me together because often the emotions get so intense that I feel like "I" just dissappears
It's obvious that you trust him very much and thats great. Smiler the intensity sounds very hard to feel but also cathartic maybe??? I wonder what effects has this hidden anger and other feelings has had on your body before being able to express it. I know for me as a person with chronic pain, I KNOW thar even though I had many of my illnesses before my trauma disorder, as well as pain... it was made much worse through the traumas.

You don't have to be sorry for, as you say.. going on so long... lol... I really love what you shared and it feels so good to be connected at a deeper level where we often do not share....

I LOOOOOOOOOVE your poem.... in all of the fear, trauma sadness, there is this wonderful hope.. that ember that keeps burning!!! Just What is it that allows us to survive but we do!!! I looove the line "I will wear this mask u ntil I have a face"... wow Smiler

DO you share your poetryu with your therapist???

Thank you for the links. I will check them out!

Hugs again and thanks again for sharing so much today,.

Butterfly Warrior
Butterfly Warrior,
Thank you, thank you, thank you for your very generous response to my post. It was incredibly wonderful to read all you said in your reply. And thanks so much for cyber hugs, I'm sending them right back. Smiler

Just hearing you talk about what you've been going through in therapy, especially your experience with different therapists provides such a sense "normalness." Knowing I'm not the only one to go through this helps enormously. And you're right, if it hadn't been for my first T, who was an incredible woman, I would never have been able to walk into my present T's office, let alone do the work with him that I'm doing.
Thanks for saying I am brave and amazing, but I'm sure you'll understand when I say it doesn't feel that way. It all sounds coherent when I talk about now but along the way its been incredibly painful and confusing and scary. But the amazing part has been the fact that my T justs refuses to budge, slowly proving to me, sometimes over and over, that he'll stay. I still struggle to trust him all the time but the fact that he's willing to hear it and his incredible patience in reassuring me over and over (I'm telling you, my head would have exploded months ago! Big Grin) is slowly wearing me down.
Anger has always been a BIG issue with me. My dad was physically abusive also and when he was enraged, usually after a few drinks, both things and people got hurt. I have very few conscious memories of this, but my older sister has told me about times that I was present but don't remember. For the longest time, I couldn't even acknowledge my anger. Years ago, when I was working with my first T she co-led a group therapy which she asked me to join. There was another woman in the group who was angry all the time, about EVERYTHING, but would never admit to being hurt, although it was painfully obvious that she was in a lot of pain. I saw my reflection in her, that I was capable of showing all my hurt, but couldn't recognize any anger, although I think it was pretty obvious to other people in the group. Smiler I actually disappeared on my T for awhile after the group ended because I think it was so scary getting near my anger. I called her back like a year and a half later, apologized for leaving without any explanation and told her I had found my anger, now what do I do with it? The anger coming out now is all the feelings around the trauma and my parents that I buried really deep partly out of fear of becoming my father and partly out of fear that expressing anger didn't go over real well in my family if you weren't my dad. Just last week I had a major breakthrough. I was talking about having wanted to really hurt my mother and how awful that was, and my T said "that's anger, everyone feels that way sometimes" and I said, I can't be letting my anger out, nothing's getting broken and no one's getting hurt. He said, "that's violence, not anger" and told me I'm not my father. It was like the biggest lightbulb in the world went off when I realized that anger and violence are separate things and not the same thing at all. The relief comes in digging out those deep lies which we don't even realize we believe and learning that its ok to have feelings and that people won't leave when I express them. Even being able to talk about how I feel on this site is healing because being seen for who I am is the most terrifying thing in the world. And sometimes this gets incredibly confusing and painful but fighting through to the epiphanies is worth it. You can be in pain and use all your energy to contain it, or you can be in pain and use your energy to move past it. I try to choose the later more often, although I'm not always successful. It's seriously hard work. And you're right, it has affected my physically. I am seriously overweight, have been my whole life, because I use food to stuff the feelings down, and compensate for the lack of intimacy. I also have adult onset asthma which gets triggered by stress. My body is like if you won't talk about it, I will. Smiler
I'm really thrilled you liked the poem. I just started writing poetry again for the first time in thirty years because it seems the only way to express how I'm feeling. And even better, but as I integrate these memories and feelings, it feels like space and energy is getting freed up that can be used to create. Really wonderful. Letting other people read it is SCARY so I can't tell you how great it makes me feel that you liked it. The hope I keep finding in the poetry suprises me a lot too, but I'm so relieved to find it. I actually wrote this in response to some really intense feelings that came out and remembering how badly I wanted to die when I was kid because it seemed like the only way out. I'm really grateful to God that another part of me wanted to live even more. But I must give credit for the last line about the mask to CS Lewis. He's one of my favorite writers and actually has a book called "'Til we have faces." He wrote in one of his essays about how feelings follow actions, that we in effect "put on a mask" by acting in way we think we should and then grow into that mask so that it becomes our real self. I always loved the concept and it seemed especially appropriate here. I'm glad it touched you. I have shared my poetry with my T but we haven't talked about this one yet.
OK, now that I've finished my novel... thanks again for talking with me and for your warmth and kindness. I love hearing your reflections on the process. You have an incredible strength and courage that you seem totally unaware of. It shines through like a beacon and its a real blessing to see.

AG
Hello AG Smiler

Aha, CS Lewis... I always think of hinm in relation to the Lion, the Witch and the Wardrobe... I used to take 'adventures in the closet" head trips I believe in part because of this book. It was a fabulous escape.. lol.


I have heard the anaology of the 'masks' we wear in many areas, sociology, psych, etc and it makes a lot of sense to me which is why I have a longing for inner and outer congruency. I think it's hard to meet people whom you feel are truly congruent and I have met some like htis. It's absolutely wonderful communicating with them!!

I have so much to say in response to your post but im too tired right nbow however, I wanted to share somerthing I had written down in my journal awhile back from this BEAUTIFUL book that I read called "YEsterday, I Cried" By Iyanla Vanzant. It's one of my favorite books because it is one of the first books/stories that I found that had so much that I could relate to in my own core.

Anyways here are a few things I wrote down from there some years back that I thought of when reading your post:
******Journal Entry*********
Some quotes that helped answer questions for me, reflected my own search and healing, etc... from Yesterday, I cried.

"Angry tears create stiffness and heat in the body, because when we are angry, we ussualy don't know how to express what we feel. We definately don't want anyone to know when we are angty because anger is not acceptable or polite. Rather than display anger, we hold back, and the tears rage forth, shattering our self image. More important, angry tears reveal to those around us our vulnerabilities. This, we believe, is not a wise thing to do."

"...I was angry because I felt so vulnerable, so exposed, and so inadequate. I was angry because I felt so powerless, and that made me sad."

"... than there are shame-filled tears, which fall when we are alone with our thoughts and feelings. Shame- filled tears come when we're judging ourselves, critisizing ourselves, or beating up on ourselves for something purely human that we have done yet can't explain to ourselves or to others..."

"When you meet anyone,
remember it is a holy encounter,
as you treat them you will treat yourself.
as you think of them you will think of yourself.
Never forget this,
for in them you will find yourself or lose your Self"
- A course in Miracles

********End*********

It's always or to me, it's just so rewarding to be able to connect on such a deep vulnerable level and yet no, we haven't disintengrated from sharing such parts of the process. How does it feel in the body?

To me, I feel somewhat more open like their is breeze in me and oxygen flowing inside of me ....

more to come

BW
BW,
Thanks for the quotes, many of them definitely resonated for me. I had never heard of the book but my library had a copy so I put in a hold on it, I'm looking forward to reading it. And respond whenever you have the time, I know how crazy life can get, and from your other posts I know that sometimes just doing the typing can be difficult for you.

AG
Butterfly Warrior -

I know this was posted awhile ago, but I just read this post and, wow that article really turned on a lightbulb for me! I even emailed it to my therapist with the part about shame based therapy highlighted and some of my thoughts about it and how it really described me well. bewilderingly so...

It was actually really validating and reassuring in ways I can't express right now.

Thanks so much for posting it!


AG -
I just have to say that your story, and your poem is profoundly beautiful... these words brought tears to my eyes (in a good way):

quote:
No one else seems to feel this
How not, when the very air screams?...


and

quote:
I will not abide in isolation
Thought I do not believe what I hear yet
still I will choose to trust
I will wear this mask until I have a face."


thank you AG - you have a beautiful heart. Smiler
ditto from me, i just printed that part about shame. i know so often things really ring my bell, but this is exactly IT! this supports the chinese water torture of my childhood, and the evasive subtlty of it as well. T1 said PTSD, but this shame thing is most accurate. it is not fear of my life being taken, it is more the fear of living it out! i think you know, and no 's' stuff, but overbearing anxiety at just what, i don't know. anyway, taking this right on into T3 monday and i hope we can cut to the chase on some of this.

really good article, thanks millions, and mega hugs to you all, as this is really tough stuff. and long term i gather...have heard too many times that it took a long time to get where i am, and it is going to take a long time to undo it.

but it helps so much to see something that seems to cut through that narrow spot of pain. so thanks BW for posting this all, and your powerful replies, AG. my heart goes out to both of you, and glad, too, janedoe that this resonated with you as it did me.

gives me hope. thanks, jill

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