Sunday, June 14, 2020

Shifting Boundaries: Therapeutic Work and Leadership

I cannot think of anything in the last 50 years that has caused such a sudden and widespread disruption of global life and work. The invisible virus and our responses to it have redefined our lives in a very tangible way. Previously unimaginable restrictions have been put in place. Our boundaries in life and work have been redrawn. In some occupations, work has been made impossible. For example, air travel. In others, there has been a rapid reorganization, with many implications, which we do not know yet. Ordinary, everyday experiences have a beginning, a middle and end. In this situation, while there will be an end, we do not know when it will be or what it will look like. We are in a daily situation of huge uncertainty. However, at the same time the restrictions put in place, seem to have provided containment for some traumatized young people, and maybe others, who have found the narrowing down of daily life to be less challenging. Joana Cerdeira, a psychologist and supervisor in residential care, Portugal, commented,
Some children who are usually very disorganized appear to have settled quite well. It is almost as if the physical containment that arises as a result of the pandemic, provides safety. 
The Importance of Boundaries
My work has always been with services to children and young people who have suffered from trauma and other adversities. I no longer work directly with children but with individuals and organizations who do. In work with traumatized children, the establishment of clear and appropriate boundaries is a central part of the work. This is true of all therapeutic work. One of the main reasons for this is that complex childhood trauma involves a lack of boundaries. The child may be treated as if she has no personal boundary, for example, in abusive situations. The child may not be recognized as a child with her own needs. She may be used to gratify an adult’s needs. Therefore, the boundaries between people and roles are confused, muddled, inconsistent and sometimes non-existent. Bessel van der Kolk et al. (2007, p.424) summarize why this is so important,

“Since interpersonal trauma tends to occur in contexts in which the rules are unclear, under circumstances that are secret, and in conditions where issues of responsibility are often murky, issues of rules, boundaries, contracts, and mutual responsibilities need to be clearly specified and adhered to (Kluft, 1990; Herman, 1992). Failure to attend strictly to these issues is likely to result in a recreation of aspects of the trauma itself in the therapeutic situation.”  

In therapeutic work, there are many reasons why clear boundaries are so important. A person without personal boundaries is an undifferentiated person, or what Donald Winnicott (1962) called an unintegrated person. A sense of personal identity and self is usually well on the way to being established in early infancy. The infant begins to know that her mother is a separate person with her boundary. This is a difficult and even frightening realization. The infant may try to control and merge with the mother as a defence against this. Growth takes place because of the mother’s firmly held boundary and containing presence. Her presence is not one that is always free of anxiety, but one in which anxiety can be thought about rather than reacted to. 

Boundaries that are firm, clear and consistent help contain anxiety. In other words, boundaries help provide structure. Events in daily life that have a clear beginning, middle, and end can be understood and internalized. Those that work with clients whose boundaries are weak or undeveloped, and who have difficulty containing anxiety, know the consequences where boundaries become unclear. One person I work with, Rui Lopes who is a Director of a therapeutic residential home for young people told me recently,

“It has never been so evident how the emotional state of the adults affects the states of young people. When an adult is anxious, nervous, and sad, kids are reacting to that – mirroring the state of mind and the emotional states – I have never seen that so strongly before.”

Once an adult in the work situation becomes unable to contain his anxiety, this also becomes uncontaining for the child for many reasons. An adult who cannot contain his feelings, will not be able to contain a child’s. A child’s past traumas may be associated with an overwhelmed adult – when adults were most likely to lose control and become unsafe. Consistency, the ability to think and to be non-reactive are all challenged when overwhelmed. What is felt inside is all too suddenly felt on the outside and vice-versa. The boundary between internal and external worlds is lost or weak. Improving this boundary is a major task of therapy. So, the person is more able to distinguish between the two. For example, what a traumatized child feels about herself may also be what she believes others and the world to be like, and vice-versa. For instance, I am dangerous – the world is dangerous. I am unlovable – others do not love me. Experiencing that the two can be separate is a slow and fragile process. The steadiness of an adult with a clear sense of their boundaries, but receptive and attuned to the child is the basis for growth. 

Setting and Breaking Boundaries
Different boundaries have different levels of permeability or flexibility. Some boundaries must not be broken or crossed under any circumstance. These may be described as absolute limits. There are other boundaries, that we expect to be tested and crossed. Emotional growth may not even be possible without testing and crossing boundaries.  A boundary draws a line between what is allowed and what is not. The line must be flexible enough to allow enough of whatever is desired but not too much. For example, saying to a young person, you can go out but need to be back by 9 pm. This may be containing for the child and it may also create an interest and curiosity in what happens after 9 pm? It can be argued that the boundary sustains desire of something a little out of reach. We want children to be protected from negative external influences, but we also want them to explore and learn how to manage themselves in the world. The child psychotherapist, Phillips (2009, p.1), in his paper ‘In Praise of Difficult Children’, said that, 
The upshot of all this is that adults who look after adolescents have both to want them to behave badly, and to try and stop them. 
Phillips (p.2) says that the adult provides something to truant from and the adolescent discovers something to truant for. In therapeutic work as well as in ordinary development, there is often hope when boundaries are challenged. When a true sense of self starts to emerge in a previously compliant child, for instance.  We start to see the ‘true’ rather than ‘false’ self (Winnicott, 1960).  Child and Adolescent Psychotherapist, Van Heeswyk (1997, p.3) explains the ambivalence involved in this kind of boundary setting,  

“Typically views held by adults in regard to adolescents are, to say the least, ambivalent.  We see them as vulnerable victims, or as young sadists who inflict terrible damage on others; we fear them as posing grave danger to our cars, property, jobs, morals and way of life, or fear for them as an endangered species requiring special protection; we envy their freedom and hopefulness, or cling to them as the only hope for ourselves and the planet; we curse and constrain their wild impulsivity, or seek to facilitate and encourage their escape from the repressive convention that constrains the school-children that they were and the adults they will become.”

The same kind of ambivalence towards the restrictions imposed by the virus situation has become clear. Protesters (boundary breakers) are both criticized and praised. It all depends on which side of the fence you are sitting.

Different Types of Boundary
The following are different examples of boundary that we need to be aware of and manage in a way that is supportive of the therapeutic task.
  • Boundaries between the worker/caregiver and child
  • Boundaries between children
  • Boundaries between workers, professional disciplines, roles, and departments
  • Physical boundaries, within the home, marking personal spaces, e.g. a child’s bedroom
  • Personal and professional boundaries
  • Boundaries around behaviour, i.e. rules and the limits of what is acceptable and what is not
  • The boundary between the conscious and unconscious
To support the therapeutic task the whole organization will need to be clear about its boundaries (Barton, Gonzales, and Tomlinson, 2011, p.129).  Boundaries can be literal and tangible, like a fence or wall or they can be implicit. In one home I worked in we were replacing the garden fence. Even when the old fence was knocked down the children still asked if they could step over the boundary, to get a ball for example. The boundary was still clear despite the removal of the physical marker. The children were contained inside the boundary not literally by the fence but by their relationships with the adults. With young people who have suffered complex trauma, physical and tangible boundaries can be especially important. Menzies Lyth (1985, p.245) explains how having a clear boundary, such as a door where permission to enter must be given, can have a positive effect on the development of identity, 
It gives a stronger sense of belonging to what is inside, of there being something comprehensible to identify with, of there being ‘my place’, or ‘our place’, where ‘I’ belong and where ‘we’ belong together.
Boundary Changes Due to the Virus Situation
A profound characteristic of a virus is that it is invisible as it travels from one person to another. There is a complete lack of boundary for the virus. The virus cannot live without infiltrating a host. A person we are close to may also be toxic with potentially disastrous consequences. The virus does not discriminate between people. So, someone who looks after you may also be a danger by being too close. There is a parallel to the root of complex childhood trauma. Where those who are supposed to love and look after you, hurt you. The psychological, as well as biological implications, are clear for those who work closely with vulnerable people. In therapeutic work with traumatized children, the concept of emotional contagion is familiar. As Lanyado (1989, p.140) described,

“Disintegration is catching – and the staff are prone to it too.  At times staff may feel anxious that they too could collapse like a house of cards. This is an extreme situation – but I am sure there are few of us working in these settings who don’t feel this way at times.  The child’s extreme anxieties can eventually threaten the integrity of their closest adults.”

This is relevant to the concepts of vicarious trauma, secondary traumatic stress, toxic stress, and burnout. Now alongside the potential emotional contagion, there is also the risk of physical contagion. The two also feed into each other. The physical risk can cause anxiety, which if it is chronic can weaken the immune system. A person’s life may be at risk due to anxieties about the virus, rather than the virus itself. Therefore, the management of anxiety is vitally important to contain and hold such a fragile situation. This is central to the task of everyone involved – leaders, managers, carers, and therapists. It always is important but is brought so sharply into focus during a crisis. A calm, regulating presence is required.

The family therapist and leadership consultant, Friedman (1999, p.232) uses the metaphor of a transformer in an electrical circuit to describe the process of containment. The electrical current (anxiety) enters the transformer. The transformer can either be designed to step-up or step-down the current. He refers to a comment made to him, 
My mother was a step-up transformer, all right. If there was anxiety in the room and she was present, you could count on it escalating. It went into her at 110 and came out at 11,000.
Friedman claims that it is presence rather than action that tends to calm down anxiety. He believed that it is presence and being that counts, not technique and know-how. He argued that this is true for parents, leaders and therapists. But as he explains (p.232) this is not easy, “Part of the conceptual leap from action to presence is that all leaders, parents, or presidents, have been trained to do something – that is to fix it.”  

He continues, “To the extent that leaders and consultants can maintain a non-anxious presence in a highly energized anxiety field, they can have the same effects on that field that transformers have in an electrical circuit”.  One unhelpful and defensive way of appearing non-anxious is to shut-off or disconnect. As Friedman (p.183) states,   
Anyone can remain non-anxious if they also try to be non-present. The trick is to be both non-anxious and present simultaneously.
What is the Impact of all this?
With the pandemic, we have experienced a huge change, along with fear. There has not been much warning or time to process all these changes. The impact upon us is potentially exhausting to deal with. Some people have remarked how tiring it is to be staring at a screen all day with online meetings. While there may be some truth that online work can be tiring, it is difficult to know how much of the tiredness is more a symptom of dealing with change. Change can be exciting, especially when we have time to make a choice. Change forced upon us without warning is more likely to provoke, fear, anxiety, and uncertainty.

Therapeutic processes tend to have high levels of predictability and consistency. They are usually negotiated with a degree of control. It is part of what can make things safe. Now everything is suddenly different with so much unknown. Some of the boundaries are gone and management of boundaries is less controlled. The space of the meeting room has suddenly changed into the family domain with all the potential interruptions and distractions. Of course, how these things are managed can be a valuable part of the therapeutic work. 

Relationships, in general, can become less clear during this crisis. Who is the carer and the cared-for may not be so obvious? In therapy work, clients are likely to inquire about the health of their therapist, etc. In the present circumstances, these questions may be an objective and healthy concern rather than a neurotic symptom. These changes alter the nature of relationships. What is shared or not between people, changes.  The normal hierarchies are challenged. This is not necessarily a bad thing, but it means we might be uncertain where the boundaries are. Friedman (1999, p.182) who referred to leadership as belonging to everyone from parents to presidents, claimed that, 
Leadership begins with the management of one’s own health... and “…a leader functions as the immune system of the institution or organization he or she ‘heads’.
Our health is largely influenced by the state of our immune system. This, in turn, is influenced by many factors, what we eat, exercise, how much we sleep, stress, and our support network. The Virus situation has disrupted our daily habits so there is a need to adapt to stay healthy. For example, we may need more sleep to process and recover from the challenges we are facing. We may need to find ways of exercising indoors. The way we keep connected and make use of support networks will have changed. To reduce stress some people have found it helpful to manage their exposure to news and social media. All of this is a vital part of self-management. This kind of adaptive response, as well as helping to manage a difficult time may also lead to personal growth.   

Friedman argued that an immune system is primarily not about fighting off threats but preserving the integrity of the organism. It is fascinating how he wrote over 20 years ago about viruses in a literal and metaphorical sense. He explained how a virus or 'parasite' impacts on cells, individuals, families, organizations, and societies. He claimed that the processes from cell to societal levels were universal and could only be managed at all levels by a healthy sense of self-differentiation. So, the first vital thing we need to do is to manage our self and do everything possible to be in a healthy mind-body state. To be a calming self-differentiated presence. Such a leader can be present amid emotional turmoil, actively relating while calmly maintaining a sense of direction. With this capacity, he or she can affect the whole system of relationships and reduce the level of anxiety in it, whether it is a family, organization, or society. 


Barton, S., Gonzalez, R. and Tomlinson, P. (2011) Therapeutic Residential Care for Children and Young People: An Attachment and Trauma-informed Model for Practice, London and Philadelphia: Jessica Kingsley Publishers

Cerdeira, J. (2020) Psychologist, Supervisor (consultant), Residential Children’s Home, Portugal – Comment on LinkedIn 13th April 2020.

Friedman, E.H. (1999) A Failure of Nerve: Leadership in the Age of the Quick Fix, New York: Church Publishing, Inc.

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

Kluft, R. (1990) Incest-Related Syndromes of Adult Psychopathology, Washington, DC: American Psychiatric Press

Lanyado, M.  (1989) United We Stand, Maladjustment and Therapeutic Education, Vol. 7, No. 3, p. 136-146

Lopes, R. – Director of Residential Care Home, Portugal, Comment – 2020 04 15

Menzies Lyth, I. (1985) The Development of the Self in Children in Institutions, in Containing Anxiety in Institutions: Selected Essays Vol. 1., London: Free Association Books (1988)

Phillips, A. (2009) In Praise of Difficult Children, LRB Vol. 31 No. 3, London: London Review of Books

Van der Kolk, B.A., McFarlane, A.C. and Van der Hart, O.  (2007) A General Approach to Treatment of Posttraumatic Stress Disorder, in Van der Kolk, B. A., McFarlane, A. C. and Weisaeth, L. (eds.) Traumatic Stress: The Effects of Overwhelming Experience on Mind, Body and Society, New York: Guilford Press

Van Heeswyk, P. (1997) Analysing Adolescence London, Sheldon Press

Winnicott, D.W. (1960) Ego Distortion in Terms of True and False Self, in The Maturational Process and the Facilitating Environment (1972) London: Hogarth Press and the Institute of Psychoanalysis

Winnicott, D.W. (1962) Ego Integration in Child Development, in, The Maturational Process and the Facilitating Environment, Hogarth Press and the Institute of Psychoanalysis: London (1972)

Thursday, May 14, 2020

The Therapist in me: The Art of Being a Creative Play Therapist During a Pandemic (May 2020)

It is my pleasure to introduce this 2nd guest blog by Carol Duffy. Based in Mayo, Ireland, Carol is a child and adolescent psychotherapist specialising in play. She is also a clinical supervisor and trainer. She has over 15 years’ experience working with attachment disruptions, trauma, and sensory regulation. Carol is married and mum of three vibrant and wonderful children.

This blog captures essential therapeutic and human qualities. Namely, the capacity to sit with ‘not knowing’ and facilitating a holding environment so that growth and development may emerge. In doing this Carol shows how she experiences feelings of vulnerability as a therapist, a parent and perhaps most importantly as a person. The vulnerability but also wisdom of ‘not knowing’, has long been a bedrock of psychotherapy. Carol vividly illustrates how the Covid-19 pandemic has added new layers to this position.

Using the metaphor of Michelangelo’s work as a sculptor she shows how we may focus but at the same time allow space for the emergent process to take shape. We have the science to ground what we are doing, but the process of therapy has more in common with art. Marion Milner who was a psychoanalyst and painter has written of ‘wide-angled attention’, which is receptive by not focusing (‘when I paint a tree in a field, I look at everything except the tree’. (in Phillips, 2019, p.14)) 
In the same way in therapeutic work, we look around the presenting symptom and not just at it. 

This relationship between art and science is captured by one of the renowned neuropsychologists Carol mentions, Allan Schore, in the title of his classic book – The Science of the Art of Psychotherapy. I hope you enjoy this blog; I think there are so many layers to this poignant piece of reflective writing.
Patrick Tomlinson

When I was in school, I remember learning about Michelangelo the sculptor. I was always fascinated by the majesty of other people’s artwork. Struck because my hands, no matter how they tried could not create such beauty. The magic came from within the artist. I tried to draft my carbon copies but to little success. I watched and tried to learn the ability, but I could not. 

I see my daughter attempt similar trials and to the same end. I tell her that her creativity lies in many ways and is not defined by what necessarily looks pretty or perfectly formed. The beauty of what she generates lies in her unique approach to it. But why should I expect her to understand at 9 what I still grapple with it at 40? All I can hope for is that she will take this in - that it will shine through like light in dark moments where she doubts herself and wonders why her pictures are not like the others.

That is what Michelangelo did for me. It was explained to me by an inspiring yet none the less forgotten teacher (in name but not in spirit), that Michelangelo never fully knew what he was going to sculpt. He became familiar with his rock and as he chiseled and worked with it (not at it) he could see a force or entity trying to be seen and escape itself. He felt he was, together with the rock, working towards a transcended view of something that was always there. He was the catalyst for the beauty but not the master of it. This, at least, was how my young mind interpreted it. To be truthful I have never sought to fact check this because of what it stirs in me. It speaks to me of trust. Trust in a process.

In my work as a child and adolescent psychotherapist, the imagery of Michelangelo sculpting was often how I visualised my practice. Being in connection with someone and trying to nurture a positive contact experience. One whereby, both my clients and I felt the wonder and excitement of what we could co-create through our relationship.

The therapeutic relationship and generating a feeling of safety, from which creativity and endless possibility could sprout, was the essence of my practice.

Reading the work of Stephen Porges, Jaak Panksepp, and Allan Schore amongst many more, including pioneers such as Bruce Perry and Bessel van der Kolk, solidified my belief systems and rooted them in neurobiological evidence. I realised that the most potent object and resource in the therapy room were myself and the use of myself. I used my voice, my eye contact, my breath, my proximity, my seeing and hearing of my clients and my responses in kind, to create attunement and safety. I intended to cultivate a therapeutic relationship that could carry the pregnancy of the person’s self-actualisation. In doing so, I too experienced change, wonder and growth. Each time. There has not yet been a client who has not gifted me with some inner knowledge of myself that I did not fully have before. I trusted the process.

I could be an external regulator and communicate safety even amid working with extreme fears. The capacity to externally regulate paved the way for more meaningful contact and the power to create and imagine in, to all sorts of places. New solutions could be tried, thrown away or mastered. Positivity could flourish rather than fear and defensiveness. A relationship of genuine warmth and knowing could emerge fuelled by unconditional positive regard.  This was possible, I believe because of the opportunity to be together in a meaningful way. Playfulness activated greater levels of joy and in a symbiotic way. The play powered a deeper relationship whilst the relationship boosted greater playfulness.

Then the world met a global pandemic. Never had we all collectively been exposed to the same threat at the same time. Not in my memory at least. Never had we all collectively experienced such a sudden assault on our ways of being in the world. Not at the same time. It made me think of the inescapable terror and oppression that so many in the world were already enduring. I felt I had no right to complain or feel any real fear in response to this. I was safe…wasn’t I? I had food, warmth, my family. No one was going to run me from my home or drop a bomb on my quiet rural little village in the west of Ireland? My children had space to run outside and a family who loved them. I was instead haunted by the many others who faced this pandemic from a much less privileged position. I felt guilty when I succumbed to pangs of panic and overwhelm.

I never really saw myself as so privileged before but now I realised what privilege was. It was to forget what being privileged meant.

In this way, some silver linings emerged in the form of gratitude and a greater, more in-depth appreciation of my fellow women and men. How we are “not in the same boat”. That is not to say I did not appreciate or reflect on other people’s struggles before. It is truer to say I had had to find ways to stop myself from doing this because it overwhelmed me. Often people asked me about my work, and I would get many responses with the most common being, “I don’t think I could do that”. I always replied that I found it much easier to work with trauma and attachment issues than to just read and hear about them. To only read/hear about these issues often amplified a sense of hopelessness, despair and panic. But now I could not shut it out. I felt overcome with emotional pressure. I needed to do something. But what?

This is when my old childhood struggle resumed. I watched the psychotherapeutic and play therapy community spring into all sorts of action. The speed of the field’s response in many ways threw me off my feet. This is not a complaint but more a reflection of the speed at which things were moving. First, globally and subsequently in my field of work where I had become accustomed to a more reflective position. But was that the truth? Was this time just revealing to me my old inner fear and introject?

I just was not good enough? My pictures do not look as good as all the rest.

Self-doubt reared its head like a young stallion and threatened to bolt. This is when I realised, I needed to self-regulate first. I could not create, imagine in, or feel positivity and possibility flow. Because I was dysregulated, I most certainly couldn’t externally regulate anyone else. I needed to dig deep to find my inner wisdom and then further again to allow myself to listen to it. Knowing when you cannot regulate is just as important as the capacity to regulate another including yourself. Just as when the mother of a newborn, realises she is exhausted and cannot go on without some small reprieve. Some moment of calm that she can claim as her own, so too did I need a moment. A moment to breathe. To take in what was happening. To realise that relatively I was not too badly off, but I was still entitled to my reaction.

Culture and society can inadvertently paint pictures of how something should look. For example, many young parents struggle on and do not ask for help. Society tells them they should be grateful and enjoy their baby - they are the ones who should be able to soothe. Social media floods parents with images and positive affirmations reminding them of just how far away they are from that unattainable perfection that seems so real. If we are fortunate, we might hold onto Winnicott’s vital concept of the good-enough mother! In general, many people cannot find a way to be vulnerable and show the pain they are in. Many, many, many of us feel the weight of that taboo. That invisible leash that pulls us back from saying we are not okay when we feel an unseen but very real pressure that tells us we should be fine and able to manage. I felt a similar expectation as a therapist.

I should know what to do. I should be doing more. But I do not know. I am scared too. I cannot admit it because I am one of the people who are supposed to not be scared and to know what to do…aren’t I?

I realised; I now needed some external regulation. It was too hard to do it on my own. I needed an inspiring teacher just like before. I needed relationships and their comfort and soothing. Time to myself to activate my capacity to heal and recalibrate. This is the essence of self-regulation. To know what you need when you need it and to be able to access it in turn. I read what I could when I could, and I chose carefully. I used my supervision. Not to find a solution but to allow me to stretch my tolerance for not having one. I stopped trying to hide the anguish and surprisingly this facilitated greater clarity and capability.  I fell back on my convictions and remembered why I had them.

I trained in tele play therapy and slowly but surely found my footing. I was not moving as fast as others but likewise, I was not moving as slow as some. Then I remembered that it did not matter. Moving fast or slow is irrelevant once you consider your capacity to regulate and support the finding of safety with others. The capacity to cultivate safety in another relationship hinged on my capacity to feel safe within myself. This capacity is a fluid rather than a fixed thing. An ever-changing and moving concept, always echoing some aspects of my current situation. The current situation now was a global pandemic. Everything I thought about, what I did and how I did it was under duress. All my structures and plans were suddenly removed with immediate effect. This requires a breath. This was not an echo of past trauma but was current and happening now. By the same token reverberated off the ghosts of the many times when I had felt unstable and unsure. When I thought that my drawings could never make the grade.

I attempted to hold on to my authenticity and to proceed with care. There were strengths and benefits I discovered along the way and there were things that I missed. I was surprised by my ability to relate and still engage in an online forum. I was grateful and attracted to what could happen in this virtual space. But I miss real voices and real faces, and the real sound of someone’s breath and laughter. There is no virtual or technological replacement for that, for me anyway. We have all lost some things in this time, some more than others. We have also found certain things in this time, some more than others. Time itself, often being one of those things. Time is also one of the things where there are huge differences in what some have lost or found.

Loss and new beginnings are truly entwined in this transitional space of uncertainty and possibility. But uncertainty breathes anxiety, just as possibility breathes hope.

So, this paradoxical place, we all find ourselves in can be quite disorganising for us. Couple this with the fact that none of us knows what will happen next. We are all in a place of wondering and as such must be seen, validated and understood in how we preoccupy ourselves with that.

So, as I move forward in my work as a psychotherapist, I try to remember that finding my capacity to regulate in relationships starts with myself and indeed my relationships with others as they scaffold me. As therapists, we deserve what we try to offer our clients and what that looks like is different for each of us. The creativity and the magic lie within us individually. And I will try to approach this as Michelangelo did and come to know what needs to emerge.

I do not want to “do” therapy in this pandemic. I want to “be” the therapist; my therapist; me. This is who I am. The therapist in me.

Phillips, A. (2019) Attention Seeking! Penguin Books: Random House, UK

Carol Duffy

Contact Carol Duffy if you have any questions

See Carol Duffy LinkedIn Profile for more information

Thursday, January 30, 2020

Creative Psychotherapy with Developmental and Complex Trauma

It is my pleasure to introduce this guest blog by Carol Duffy. Based in Mayo, Ireland, Carol is a child and adolescent psychotherapist specialising in play. She is also a clinical supervisor and trainer. She has over 15 years’ experience working with attachment disruptions, trauma, and sensory regulation. Carol is also married and mum of three vibrant and wonderful children. As this blog shows, she fully understands the importance of safety, regulation, attunement and repair after ruptures in relationships. It also shows the value of play as a healing process. Carol describes beautifully how play and safety are so connected in therapeutic work. I hope you enjoy this thoughtful and insightful blog and please do share.
Patrick Tomlinson

Part 1
The deceptive simplicity of psychotherapy using play and creative approaches is quite paradoxical to explain. In many instances, it must be seen, felt and experienced to be fully understood. There is a wealth of science available to us now to consolidate what we as creative psychotherapists experience and contemplate so frequently and fluently in our work. Play and creativity are often cited as having transformative, therapeutic, healing and reparative potential, amongst many other qualities. However, when does playfulness become therapy? When does creativity, joy and spontaneous laughter become healing and reparative?  
There is an abundance of research that indicates what we need to pay attention to. There are evidence-based strategies that tell us what to do. But none of these matter unless we pay close attention to the ’how’ of what we do and realise that our greatest ’tool’ is the use of ourselves. While we can describe a symphony of wonderful play ideas that are designed to activate wellbeing and interrupt trauma-induced behaviours - if we are not playful, then it’s not play. It becomes more of the same...another intervention full of good intentions, that is not useful to the client. The intervention becomes part of the story of origin and cannot possibly interrupt it.

In the ninetieth session with my teenage client, I was simply brushing her hair while she imagined her future. Her future had hope, realism, and possibility attached to it. She imagined me in her future as our relationship had become something that mattered. She casually referred to it without flinching and without hints of fantasy. After 70 sessions a level of trust had developed, and she asked me to brush her hair. After ten more sessions, she engaged with me in thinking about her future. In the beginning of her therapy, notions of the future didn’t exist, or at least when they did, they sounded fantastical and impossible. The past sounded rosy, which of course it wasn’t.
Everything felt fragmented, disjointed and at times it was very difficult for me to stay awake. I think this was due to her deeply embedded dissociative coping style. Our clients don’t tell us how they coped and survived unspeakable terror; they show or project it into us.

In many cases having creative approaches available and a permissive environment is all they need. Their coping becomes visible in how they approach the play and/or you. But dissociation is more difficult to describe. The more entrenched it has become the more automatic it can be for the client. I noticed a heavy energy in the room, a sleepiness and a pressure so great that staying present in the moment seemed almost impossible. I imagined that for this client, staying present in her pain was simply unbearable and so she shut down. She had to shut down so much that now the coping had become automatic. This feeling of shutting down can also be felt by the therapist when they are truly attuned to their client. This has been a common experience of mine with those clients that have suffered profound and/or early relational trauma.  

Early in the therapy, my energy and therapeutic presence were entirely focused on trying to just stay with her.  Expanding her ability to even tolerate my presence, was underpinned by a visceral drive in me to pull away and a belief that I was useless. But none the less I stayed present, interested and tried to engage and communicate safety through my eyes, my voice, my body, and my self. I used my prosody, eye contact, body language and facial expressions to communicate interest. A desire to be with her and that she was deserving of unconditional positive regard.
Above all, I tried to communicate safety.  Through my reflective presence, I tried to give her an experience of herself that felt whole.

This is what we do when babies are born. We reflect back to them their being. We look at them with interest and joy, and we balance it, so to not over stimulate. We watch for excitement, interest and fear and we respond in kind. We tend to do this automatically and often without conscious awareness. It comes naturally to many of us. But for those of us who never received this, the need to have the experience replaced somehow, is fundamental. This work requires a conscious and deliberate focus. Play also offers an invitation to engage that can disarm or bypass habituated defence/coping mechanisms like dissociation.  I tried to be an external regulator and container for her experiences. This took work, hearty supervision, energy and a type of focus that is quite difficult to explain or fathom.

This is the work when we try to engage with young people who have suffered developmental trauma and attachment disruptions. The success of the therapeutic models we use rests heavily on how we deliver them. Or rather how we embody them. We use our selves, much like I described above. We give our undivided attention. We try to communicate a felt understanding and reflect back interest, validation, understanding and at times an invitation to go a little further in our journey together. It is new ground for us both. As the therapist, you must exude and communicate that this is a safe terrain. Just like any parent of more than one child will tell you, it’s a different journey with each child.

I saw my first movie in a movie theatre back in 1987. It was “Three men and a baby”. I remember my young eyes seeing Tom Selleck cradle the little baby he was suddenly responsible for after he found her on his doorstep. The tragedy bearable within the comedy. He was reading to her from an architecture magazine. His friend criticised him for his choice of reading material and I distinctly remember him saying “it’s not what I am reading, it’s the way I am reading it that matters”. My child’s brain imprinted on that message, but it is only now that science has fully explained the resonance. Porges (2017, p.187) captures this very well,
Also, we need to remember that we live in a culture where people say, “It is really what I say and not how I say it that’s important.” But our nervous system is telling something different to us: It says, “It is not really what you say – it is how you say it”.

Our nervous system responds more to the tone and physical expressions than the words. 

The work of Bessel van der Kolk (2014) and his aptly titled book, ‘The Body Keeps the Score’, illuminates the way our bodies hold the memories of our trauma, as felt physical sensations rather than conscious memories. The work of Allan Schore, Bruce Perry, Daniel Siegal, and many others on the significance of regulation and a significant “other” acting as an external regulator highlights the potential power of the attuned therapeutic relationship.

When someone engages with us playfully and communicates warmth, interest, and safety, their tone of voice and facial expression can communicate a type of felt safety. When this is paired with the fun and joy of play it creates a potent combination of both safety and connection. This enables regulation by the “other” and in turn, begins coregulation and the beautiful tapestry of social engagement. The pleasure it brings causes our bodies to crave it again. As it patterns it can then become an alternative and healthy habituated response as opposed to an automatic defensive response.

From my perspective, this also closely matches what Jaak Panksepp taught us about the importance of play as one of our emotional circuits in the brain. The joy play brings counteracts the effects of stress and fear. And of course, others such as Donald Winnicott have for a long time emphasized the importance of play in childhood development and therapeutic work. Winnicott (1971, p.44) stated the centrality of play in therapy,
Psychotherapy takes place in the overlap of two areas of playing, that of the patient and that of the therapist. Psychotherapy has to do with two people playing together. The corollary of this is that where playing is not possible, the work done by the therapist is directed towards bringing the patient from a state of not being able to play into a state of being able to play.

Play amplifies our capacity to engage positively with others. This is a crucial therapeutic power of play (see Schaefer & Drewes, 2016). Play can generate positive emotions and promote bonding. Play is a creative, imaginative process. It happens in the space between two or more people.  It is a shared experience, which also acknowledges separation and the boundaries between those involved. Play is a way in which feelings and experience can be expressed symbolically. Symbols and creative expression can communicate what cannot be put into words.

To describe the work of a psychotherapist these days who specialises in trauma or attachment, one will unavoidably be ensconced in the work of such amazing pioneers. However, the complexity and intricacies of the collective works of these people will only bring us so far. For again, it is not the ’what’ we play or how brilliantly we can describe it for that matter, that will ultimately reach our harder to reach clients…it is the ’how’ we play. Play and playfulness are felt experiences, that must feel ‘real’ to be meaningful. The simple description of finally reaching a place where I could brush the hair and nurture the adolescent child who now sat before me, did not and could not reflect the painfully slow at times pace that it took for such safety, regulation and trust to develop. Upon this, all other areas of her healing took place. This is where play and creativity became healing and reparative.

I once was asked, how do we explain what is happening, when it appears we are not really doing anything? My answer is that what may appear simplistic and ’nothing’, reflects a vitally important interpersonal process.
To support such wounded people to tolerate your very presence and to experience safety and co-regulation is the essence of complexity, and yet is deceptively simple in many ways. It is at the root of trauma recovery and attachment repair.

Good relationships can heal and repair and are the foundation of good mental, physical and indeed social health. For ordinary child development and recovery from trauma, an attachment relationship is necessary. And what facilitates attachment is attunement. An attuned ‘other’ is necessary for regulation to take place. Once external regulation has happened over and over again, the capacity for co-regulation and subsequent self-regulation grows. This is now cited across the literature and indeed, as above, in popular fiction. Relationships are portrayed as the answer to so many of life’s difficulties. Relationships can buffer, mitigate against stress already endured and protect against potential traumas. I often describe healthy relationships as being nature’s own antibiotic and vaccination all rolled up into one.

The reason for the volume of documentation and publicity is because it’s true. Relationships are that powerful and they can heal and transform the potential of people’s lives in ways that can be unfathomable. Recently Hambrick et al. (2018) highlight that the wealth of our current relational health is the most powerful predictor of our future outcomes. This even surpasses the impact of any adversities we may have experienced. This warrants much optimism. We must harness the positive and powerful regulating effects of healthy relationships, which will undoubtedly lend themselves toward the capacity to thrive following adversity.

Part 2
What happens when relationships are the very thing that we fear? What happens when the greatest danger experienced by someone is also the vessel of the healing potential?
Nature’s cure, sadly, is often also nature’s cause.

For so many people, who have experienced the harsh environments of childhood trauma where the very people they turned to for protection were the source of their terror and pain, the idea of a relationship being the answer to their problems may seem absurd and dangerous. It may feel as terrifying as it would be to stand in front of an oncoming truck. Can you imagine that feeling? The pulsing of your heart, the beating in your ears, irregular breathing, the cold panic, the desire to run, kick, and scream, or the out of control impulses that may take over? The fear may take such a hold of you that you collapse and lose consciousness. Now apply that terrified state to the seemingly attractive and benign qualities that one may perceive about the relationships we offer to those impacted by complex trauma. This sadly is the lived experience that many traumatized people have for much of their life. The tragedy is that they crave and fear the connection they so greatly need. The Shakespearean irony here often results in a classic Shakespearean tragedy. We may even hear narratives such as, ’they were offered every support going’ or ’they didn’t want the help’ or ’they couldn’t be helped’.

It is this intersection we now must turn our unrelenting attention to. The intersection of where we attempt to support another through a relationship, and they are very scared of it. This is where and when, that the ’how’ of what we do really becomes important. We know that when the body has been hijacked by overwhelming events, it becomes primed for defence, not for connection.
When trauma happens repeatedly it patterns as Perry et al. (1995) showed us, and our, “States become Traits”.

The connections in our brain that fire up in response to fear and threat, get used repeatedly and strong neural connections develop there. These essentially form the go-to patterns of behaviour in our brains. Areas of the brain which are not getting used, for example, areas that are better able to think, reason, feel joy and gentle pleasures, become a little more barren and less populated. The more populated areas become our driving seat and our ‘government’ will reside there. They direct our behaviours.

If the areas primed for defence or threat become most populated, they are also the least able to think, the least able to rationalise or contextualise. Unintegrated traumas from the past will feel present. Benign experiences that are happening presently, such as, a person offering a secure, helpful, and possibly even transformative relationship, will unavoidably remind that person of their previous other relationships. The overused and by now overactive defence mechanisms will kick in. They now have the most seats in power. They will overrule and shut down the parts of our brain that could actually help them contextualise and set this relationship apart. Without that capacity, this new relationship will melt into the same pot as all the others. Without ability to contextualise it, the threat is very real and present. The person will do what nature intended in response to a threat – run, defend, attack or collapse – all of which are designed to enable one thing and one thing only…survival.

These responses are very important and protective in the context of a real threat but become unhelpful when they are habitually re-acted. We need to be respectful to these protective reactions and help the client feel safe in the therapy context.  
Porges (2017, p.87) goes as far to say, “Feeling safe is the treatment”. 

Safety is certainly the first stage and lays the foundation upon which all therapeutic work takes place.   Kezelman and Stavropoulos, (2012) referring to the pioneering work of Pierre Janet, the French Psychologist and Psychotherapist, in the field of dissociation and traumatic memory, in the nineteenth century, state, 
Phased treatment is the `gold standard’ for therapeutic addressing of complex trauma, where Phase I is safety/stabilisation, Phase II processing and Phase III integration.

And so, we must use ourselves to externally regulate and to communicate safety above all else. We cannot do this by trying to engage the parts of the brain that have been overruled. The parts that relate to rational thoughts and reason. We harness the curative and transformative powers of play to regulate nervous systems and engage the right, emotional brain with non-verbal emotional transactions that exude calm, consistency and safe presence. Presence that doesn’t seek to change or alter the frightened self in front of us. But presence that seeks only to engage and to engage safely. Presence that recognises that if we can manage a shared smile or moment of joy together then we are on the path. Presence that remains available even in the mix of confusion and doubt. Many times, we will feel that confusion and doubt as strongly as our clients. Presence must externally regulate long before there is co-regulation and even longer before there is self-regulation. Presence that communicates, “I’ve got you. I am here. I will not leave you in this alone. I want to be with you no matter what. You will be okay because in this moment, right here and right now, I will paddle for us both and keep us both afloat.” We use our supervision, self-care and support networks in the same way, so that we can stay regulated amid this. This is the only way we can hope to offer such external regulation.

The destination doesn’t matter. Once we don’t sink, it often takes care of itself. Reaching the equivalent transformative point where the offer of nurture is accepted, such as brushing hair, and where play becomes possible, means that we are well on the journey.    Donald Winnicott (1990, p.228) using the metaphor of disentangling a knot, describes this process well,
It is emotional growth that has been delayed and perhaps distorted, and under proper conditions the forces that would have led to growth now led to a disentanglement of the knot.

Carol Duffy

Hambrick, E. P., Brawner, T.W., Perry, B (2018) Examining Developmental Adversity and Connectedness in Child Welfare-Involved Youth, in, Children Australia: Understanding Outcomes for Care Experienced Children, 43 (Special Issue 2): 105-115, Cambridge University Press

Kezelman, C. and Stavropoulos, P. (2012) The Last Frontier: Practice Guidelines for Treatment of Complex Trauma and Trauma Informed Care and Service Delivery, Australia: Adults Surviving Child Abuse (ASCA)

Perry, B.D., Pollard, R.A., Blaicley, T.L., Baker, W.L., and Vigilante, D. (1995) Childhood Trauma, the Neurobiology of Adaptation, and “Use-dependent” Development of the Brain: How “States” Become “Traits”, in Infant Mental Health Journal, Vol.16, No.4, Winter 1995

Porges, S. (2017) The Pocket Guide to The Polyvagal Theory, New York: Norton

Van der Kolk, B. (2014) The Body Keeps the Score: Brain, Mind and Body in the Healing of Trauma, Viking: New York

Winnicott, D. W. (1971) Playing and Reality, London: Routledge

Winnicott, D.W. (1990) The Maturational Process and the Facilitating Environment, London: Karnac Books

Contact Carol Duffy if you have any questions

See Carol Duffy LinkedIn Profile for more information