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May 15, 2017, 07:46 AM
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Countertransference and the Treatment of Trauma
By Constance J. Dalenberg, PhD
Quote:
The Search for a Tie to Reality
What happened-really happened.
What happened-really happened.
What happened-really happened.
I believe with perfect faith That I will have the strength to believe that
What happened-really happened.
(Carmi, 1977, p. 102)
The question of belief also can arise when the client or ther- apist feels the terror of loss of reality testing. Here, the client is indeed asking the therapist to affirm a truth, to state that the trauma occurred. However, again the client might not be seeking-as an end point-the therapist's view of the truth of the trauma. Rather, "Do you believe me?" here could mean "Tell me I am not crazy" or "Tell me that I know truth from fiction." Herman (1992) wrote that a sense of unreality in the therapist might be the first sign in the relationship that the client has an unspoken trauma history. Nonetheless, as Courtois (1999, p. 303) argued in her indispensible text on memory of sexual abuse, "in the absence of memory, neither transfer- ence or countertransference, no matter how compelling, should be interpreted as always indicative of past abuse.''
Chronic doubts in the reliability of their own perceptions appear to be the fate of many who experience chronic trauma. (See Shay [1994] for a discussion of this symptom as exhibited by war trauma victims and Davies and Frawley [1994] for a discussion of the same symptom in incest vic- tims.) Countertransference withdrawal or avoidance, or over- reliance on a "blank-screen" approach, can further under- mine a client's sense of reality. Almost 70 years ago, Ferenczi argued that a therapist's "cool" and "unemotional" attitude is inappropriate when “events are of a kind that must evoke, in anyone present, emotions of revulsion, anxiety, terror, ven- geance, grief, and the urge to render immediate help. . . . The patient prefers to doubt his own judgment rather than be- lieve in our coldness” (Ferenczi, 1932, pp. 24-25).
The therapist who empathizes (consciously or uncon- sciously) with this aspect of the wish to believe might seek to concretize the trauma prematurely to gain some hold on reality. This is particularly true when bizarre or implausible elements enter the trauma account-which is likely for a va- riety of reasons (Dalenberg, 1996b; Everson, 1997). The study of the frequency and meaning of these disclosures was one focus of the Child Disclosure Study series. In this research, a ”gold standard” sample (n = 142) was located-abuse ac- counts supported by evidence from medical exams and po- lice reports. Supportive medical evidence, a perpetrator con- fession, and (in 80% of the cases) some physical or eyewitness evidence was available for all children in the gold standard sample. In the comparison sample, a questionable account group, none of the children’s accounts were sup- ported by medical evidence, eyewitness or physical evidence, or a perpetrator confession.
Children’s disclosures of sexual abuse also were rated as severe and nonsevere. ”Severe abuse” was defined as abuse containing force or oral-genital contact, repeated abuse, or abuse by a family member with frequent access to the child. Abuse labeled ’honsevere” involved single, nonviolent inci- dents of molestation by perpetrators who were not likely to be attachment figures in the child’s life. Fantastic elements (those judged unbelievable or highly implausible by raters independent of the evidence) were more than four times more likely to occur in children known to have experienced severe trauma (the gold standard severe group) than in those known to have experienced milder incidents of punishment or molestation or those in the questionable account sample (Dalenberg, 199613). Thus, ”unbelievable” accounts of abuse are likely to be characteristic of the most serious and dan- gerous cases, leading to the frightening conclusion that the most serious cases might be most difficult to prosecute. Sim-ilar descriptions of lapses in reasoning in adult traumatized populations are given in the literature on attachment (Main, Van Ijzendoorn, & Hesse, 1993, as cited in Shaver & Clark, 1994) in portrayals of “D-like” adults (who typically have abuse or trauma backgrounds). D-like individuals are de- scribed as showing ”lapses in the monitoring of reasoning” when responding to questions regarding potentially trau- matic events. This description is said to apply particularly when participants were asked to discuss abuse or the deaths of important others. Bizarre elements or lapses in reasoning not only distance the therapist (in an observable way in our Child Disclosure Study research), but also leave the therapist feeling disoriented, confused, and uncomfortable.
The fantastic and bizarre elements of trauma accounts in children can result from a child’s misunderstanding, confu- sion between nightmares and reality, or traumatic halluci- nations (cf. Dalenberg, Hyland, & Cuevas, in press; Everson, 1997). These distortions, however, are not limited to children. Adults can show short-term reality distortion after trauma- an effect that research in our laboratory has shown dissipates more slowly for patients who also were traumatized in child- hood (Straws, 1996). These elements add to the therapist’s sense of disorientation, because they often appear within an otherwise credible trauma story.
Dissociation, a key trauma symptom about which so much has been written (cf. Putnam, 1997; Spiegel, 1994), also con- tributes to the client’s and the therapist’s sense of unreality and need for confirmation. The therapist’s dissociation to the client’s trauma or the patient’s dissociation to the memory of trauma create fundamental feelings of fragmentation in the self. The need for reality testing for such clients (or in such states) becomes quite concrete. Reaching for reality might in- clude reaching for a statement from the therapist about the past.
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