This practice report was stimulated by Kluft's editorial in a 1992 issue of Dissociation. Kluft is an expert on Multiple Per- sonality Disorder, and he was making a case for accepting our own limitations as therapists. In his field the experts are only slightly ahead of the patients in understanding MPD. They must learn while doing.
I have found this to be the case in my work with incest sur- vivors who have discovered as adults that they were molested as children. I have had to continually re-define my own role with each person dealing with this discovery. Those of you who heard my practice report last year in Boston will recall that my study of incest was thrust upon me. Personally it began when a magazine article on rape suddenly brought back memories of my own sexual abuse by my father. Professionally it developed as the social climate brought the topic of incest out of the closet and many of my clients began to recall their own memories of childhood sexual abuse.
Persons dealing with uncovering memories of childhood incest deal with multiple severe losses simultaneously:
- loss of the illusion of a more intact childhood
- loss of the person they might have become
- loss of their relationship with the abuser. This is especially traumatic when the abuser is a parent
- loss of trust - loss of control of their ability to be intimate - loss of autonomy - loss of many basic beliefs and values
- loss of innocence
The overwhelming effect of so much loss is that these persons are in the same emotional state as any person who has survived a trauma. However, because the cause of this trauma is in the past and because it is still largely a socially taboo topic, the sur- vivor is in a uniquely vulnerable position. Often it is only the survivor and her therapist who believe that the abuse actually occurred and the disbelief of significant others, whether actual or probable, leaves the survivor as alone with her pain and ter- rifying memories as many a Vietnam Vet. [By the way, do not be misled by my use of the feminine pronouns. I have never worked with a male whom I have known to be an incest survivor, so all of this work has been as a woman with women.]
Unlike the Vietnam Vet, however, the survivor's losses hap- pened only to her. Even when the perpetrator was a parent and siblings were involved, the survivor was nearly always of a dif- ferent age and birth order. And almost always the incest was a part of the survivor's "night life," repressed or suppressed dur- ing the day. When the abuse is recalled in adulthood, sharing among siblings usually only occurs when all have nearly healed, leaving each survivor alone with her therapist during the trauma of recalling her past.
The nature of this sort of loss requires special expertise and unusual efforts from the therapist. The therapist is almost always put in a "heads you win, tails I lose" position. Because, unlike in our work with the bereaved, when we work with this loss we don't have the certainty of a corpse. Some of this work is similar to work done with survivors of MIAs. In supporting our client's need to keep this uncovering work secret, we tacitly concur in doubting whether the abuse actually happened, and this secrecy heightens the horror which is a part of all sexual abuse. As in our work with all sorts of bereavement, we do not have the power to make the client better, to take the hurt away. But because our client is in this unusually vulnerable position, with even more defenses stripped away than the bereaved, we have the power to make things a great deal worse.
The most discouraging part of this report is to convey with the certainty of experience that those of us who work with these survivors will, inevitably, make things worse for them. That is the nature of this work. Because we are helping to uncover memo- ries, we cannot predict how the client will react when each memory is uncovered. And so we cannot foresee the client's paths of heal- ing as we often can with persons dealing with more ordinary types of loss. We cannot have at our hands a repertoire of responses, suggestions, and activities that work with most people. We cannot predict what is going to happen next; we cannot even give the reas- surance that full memory will come, nor that they will achieve closure and be able to allow this loss to grow old.
The losses that they are experiencing are continuing to happen in the present and will continue in the future. And we therapists are often the midwives administering aid to persons giving birth to demons. To go back to the similarities to the Vietnam Vets, we are going with them to a war zone, but with our clients, much of the war has yet to be fought. And many of the battles will be fought between us, as the client struggles for sanity while recal- ling things that happened with insane people.
Here I admit to a bias that affects my work: I am not open- minded on the topic of perpetrators. I think one must be insane to use one's child sexually. I do not deny the probable influence of my own abuse in forming this view. Neither do I apologize for it. I can understand all too well how having evil done to one can make one want to do evil, but to do that evil, one must leave the world of the sane. In my definition, a person who abuses children is, at least for the moment, insane.
It is this belief, I find, that gives me some unusual powers when working with survivors. I am able to be unswerving in my support of them. I never doubt that such abuse occurred. I never believe that they somehow were to blame, even in those conflicted situations where the abuse was pleasurable at the time. And I am always able to encourage them to continue in this horrible grief work as long as they find it necessary. I am absolutely certain that after they have rid themselves of most of their demons, that in the afterbirth will come the birth of their true selves, the person who is able to acknowledge that these horrible events did occur and to move on, dealing with them as need be for the rest of their lives.
So the encouraging part of this report is that once we under- stand and accept our peculiar roles in this process, it is possible to give aid and be of help. Though, as many of you know, this is never easy work. Being present at these births is every bit as fraught with real peril as assisting at the birth of a child. It puts me in mind of a line from Margery Allingham's book, The Tiger in the Smoke:
"Mourning is not forgetting...It is an undoing. Every minute tie has to be untied and something permanent and valuable recovered and assimilated from the knot. The end is gain, of course. Blessed are they that mourn, for they shall be made strong, in fact. But the process is like all other human births, painful and long and dan- gerous."
As I promised in the abstract, I am proposing an epistemology here. I am looking at the ways in which I, as a therapist, have got into trouble with these survivors as I attempt to minister to them, and at the ways I have got back out of trouble. And part of what I am proposing is that it will never be possible to avoid such troubles. Indeed, to try to do so will cause other and, likely, worse problems. I must tend to myself or tend to my client; there is not room to do both. And frequently, if I tend to them, I sac- rifice some of myself. And it hurts.
All of us who work with the bereaved know this sort of hurt. We resonate to our clients' pain and it awakens our own. We all are involved, then, with the problems inherent in defining and maintaining therapist / client boundaries. We already know that if we are to be effective we must be empathic. We must not abandon clients to their own hurt by remaining distant, detached. We must normalize grief by letting them in some way know that we, too, have suffered loss. We must encourage them by letting them know that we have healed, have integrated our losses, have rediscovered the joys of life. For us it is not a question whether or not to show our reactions to their stories: if we are cold fish, we are not grief therapists for long.
So we already know the importance of interacting with our clients as people as well as therapists. And it is this very know- ledge that will lead us right over the edge of the cliff in working with these incest survivors who are just uncovering their memories. When we begin resonating with their pain, letting them see our reactions as fellow humans, we run the risk of scaring them to death. And I am afraid I do mean that literally. I consider every such survivor to be a potential suicide. And now that I have raised your attention, let me enumerate those less-lethal pitfalls I have encountered.
Should one share that one is / is not a survivor? If one is a survivor, sharing this information has great power for healing. The client knows one has true empathy and that it is possible to survive this recalling process. The trap is that the client may discount one's expertise as a therapist. This may be a greater danger when the client suffers from great feelings of shame. She may see the therapist as another soiled woman and, therefore, not worthy of being listened to.
Another benefit of not sharing one's own past with the client is that one then does not have to worry about encumbering her with one's own baggage. One trap here is that one will want or need to share this information later and the client will feel misled. But if one never shares this information, and thus appears unsoiled, one abandons the client to evil. To say I have known this evil and survived can be greatly freeing for one's client. Of course, if the therapist is not a survivor, she does not have this power. So by not sharing she avoids abandoning the client to being different from her.
So, if one does not share one's past, one can always choose to do so in the future, when and if the need arises. However, once one does share, there is no going back. One will have to deal forevermore with the ways that one's own past is intertwined with this client's therapy. And things can get very messy, indeed. The whole incestual pattern, of the therapist or the client or both, can be horribly re-created in the therapy. And avoiding having that happen can exhaust the resources of the therapist. So one must weigh the possible advantages of sharing with the enormous pitfalls, and make a judgement call. That call, of course, must be based on one's knowledge and intuition about the client and about your relationship with this client.
And now that you have made your choice, either in listening right now or in your hands-on work, we come to the problem of hav- ing the choice be made for you. And this will arise more often than not. Usually it will come about when the client asks you, when you are least prepared for it, whether you are a survivor. And as often as not, you will give the answer away, even if you try one of the therapists favorite tricks, such as "How would it make a difference to you to know?" Most of the survivors I have worked with are intelligent, aware people. And had I elected to duck, some of them would surely have called me on it: "Why are you choos- ing to answer my question with a question?"
When working with the pain of incest survivors, it is inevi- table that one will be overwhelmed by the client's hurt. Should one let one's feelings show? Usually it is not possible to hide them: I cannot listen to these sorts of memories without showing my horror, disgust, and even rage at the perpetrators. Further, persons dealing with this much loss usually have extra antennae that accurately pick up the feelings of others, whether one tries to hide them or not. And it is wonderfully comforting for the client to get this validation of a reality that has been hidden for so long. But here again there are pitfalls. Acknowledging the horror the client is recalling and validating the existence of evil can be the straw that breaks a last defense, and the client will become overwhelmed. Who of us has not stayed with someone much longer than we intended to because the person is unable to pick up and leave. Or has become suicidal?
In searching for safety, for both ourselves and our clients, we may entertain the idea of making these sessions more structured than we normally do. We may consider using certain techniques, such as genograms, drawing floor plans of childhood homes, keeping a structured journal. At first blush this would seem a sensible way to proceed. Putting external structure on internal confusion is a tempting idea. And these techniques are often helpful in stimulating memory where before there were only blanks. But that sort of help may also be disastrous, bringing about recall before the emotional resources are in place to handle the new memories.
This brings up the question of whether we should push for recall, should work directly to pierce through this selective am- nesia of many trauma survivors. Clients whose memory returns in a patchy way will often cry out for this sort of help, claiming that not knowing feels worse than any memory ever could. Beware! The grass, in this situation, is always greener. To each survivor, her own particular set of defenses feel harder to bear than those she sees or imagines others to have. Those of us who were active in the Sixties' rounds of new techniques--encounter groups, per- sonal growth groups, gestalt, rebirthing, etc.--remember the very real dangers of dropping people into their own unconsciouses. It is not all that difficult to make someone psychotic, to push them into decompensating. And while never is a very long time, I would never use my own expertise with gestalt techniques in these cases.
We must have faith in the processes of healing to work effec- tively with survivors. We must believe that mental health is a natural state and that each person is a complete organism that knows more about self-healing than we do about helping them heal. While we must take very seriously our job of keeping the person alive and well until healing can occur, we must never forget that the healing comes from within the victim, not from our hands.
This means facing the fact that sometimes health will not be all that we or our clients would wish it to be. All of us who have been badly hurt have to live with our scars, no matter how well they have healed. And for some people, full memory will never come and they will have to live with shadows. They may well be able to integrate this hurt, to tell themselves a consistent story, and to live with the loss, just as I have had to do with my inability to recall what lead up to my disastrous bicycle accident in my twen- ties that resulted in a closed head injury and other memory dif- ficulties. I can tell this story in a way that makes perfect sense, but I have no recall of the accident and no definitive ex- planation of its cause. We have to accept, in our various ways, that complete healing is never possible with major loss, that we have lost the potential to become the person we might have been had the loss not occurred.
And when we face these painful facts, we fall right into the next pit. Our client may accuse us of not knowing where all this is leading, of not really knowing what we are doing. And it is inside this pit that I take comfort from Kluft's encouragement to proceed anyway. It is here that I believe in the importance of support networks among caregivers, among those of us who are mid- wives to spiritual rebirths. For that is the main loss of these survivors: spiritual centering. Trauma turns one's world inside out. Only some sort of inner faith can help one survive until the new order is established. And usually that faith must come from us, for the survivors usually have none left.
So I take the tack of both agreeing and disagreeing with my client when accused of aimless wandering. It is true that I do not know exactly how all this will end, which of many realities will be the one this client embraces. But when this uncertainty causes my client to despair, I drop the other shoe, that of self-empower- ment. I work constantly to stay in touch with my belief in this person's healing powers. I hold fast to the belief that they will, somehow, find their own inner voice and heed it. Experience has shown me that all this struggle is never without avail: it all leads somewhere.
My favorite pit-extraction technique is to clinic with my client about any of these perils that arise. I simply talk about what I think is going on and ask for their perception of same. In doing this, however, I work hard to avoid the slippery slope of seeming to abandon my client to a chaotic morass. Although I am unable to avoid many, even most of these problems, I still am the therapist; I still have expertise. I am still responsible for the well-being of my client and the fact that there is much I cannot know or do in no way lessens that responsibility. While I may now know exactly what will achieve the desired results, I am still going to try everything I can. My lack of answers does not allow me to cease questioning.
And this gets us back to the difficult question of how much of myself to share. My ability to work and wait with my client for clarity comes from my own ability to work and wait with myself. I believe because I have been able to resolve much of my own hurt and to find creative ways to live with it. That is how I know that healing is possible, not from any theoretical perspective. But sharing this with a client leaves me open to the charge that I am just reworking my own losses through them, not really helping them to struggle with theirs.
And this is the point at which the support of other profes- sionals is vital. Even though I have worked through my own issues, when I venture back into this pain in empathy with my client, I am unavoidably stirring up my own hurt. To some extent, I am rework- ing it. I am bringing myself as a whole person into this therapist / client relationship. My job is to help her find her own healing self, just as I have been helped to find mine. If I am not willing to go back into my own hurt, then I am not fully believing that healing is possible. If it is too hard for me, then I cannot help someone else.
I have presented a number of specific problems that can arise when working with adult survivors uncovering incest memories. I have looked at them from my personal perspective. Let me now step back and propose a more theoretical point of view. I promised you an epistemology of the establishment and maintenance of personal boundaries between therapists and clients. And I think we know enough that the beginnings of an epistemology can be made.
It is important to constantly note and question the therapist / client boundary with these survivors. The nature of this trauma requires that the therapist present herself as a person as well as a professional. Detachment is not only inappropriate, it is de- structive. Intervention is required on the personal level even more than on the theoretical or professional. It is imperative that if the therapist recoils from the client's pain, she will come back with her own certainty in the ability of the client to heal, and that certainty must be felt at the personal level to be cred- ible.
Because intervention must be made at the personal level, the therapist / client boundary is dynamic, never static. And the major responsibility for maintenance of this boundary is the thera- pist's. A trauma survivor does not have the ability to do this work effectively. Further, mutual trust is imperative for the client to heal. Consequently, the client must be assured that the therapist will do the major work of boundary maintenance and will do this in accord with the client's needs and vulnerabilities, not those of the therapist.
This need to view the relationship from the eyes of the client makes the therapist's work definitionally impossible. The thera- pist is unable to see the world from the client's eyes. She can only make educated guesses. Consequently, the therapist must en- list the client's help in defining and maintaining the boundary. The therapist must have feedback about the client's feelings, val- ues, needs. Thus this duty of the therapist is most difficult at the beginning of their work together, just when the client most needs protection.
Genuine humility can be the therapist's best tool during this perilous beginning. Openness about her abilities and limitations is the keystone for making the relationship a safe one for the client to enter. And client reluctance to enter into a relation- ship with unavoidable uncertainties is an indicator of whether this is, in fact, an appropriate action for her to take.
I propose that the establishment and continual maintenance of the therapist / client boundary is the foundation of healing. The relationship between therapist and client will supersede the perpetrator / child relationship which is being brought to light. If the therapist / client relationship is not healthy, then the client's healing cannot be completed there. The therapist's abil- ity to empower comes from within this unique relationship. The boundary between them changes constantly as the client works through her hurt. Attention to these changes enables the therapist to make clean transactions with the client.
In order for the therapist to receive needed support from other professionals, comprehension of the importance of this boun- dary's definition and maintenance must become central to our thinking. Just as we train people working with hospice to go into the homes of the dying, we must train each other to go into the hearts of the hurting with the skills to help heal the further damage that this entry causes. And this is why we now turn to your input.
©Copyright 1993, Cendra Lynn, Ph.D., [email protected]