Book Notes

A new book helps practitioners see how their reactions to patients' trauma can influence treatment.

BY LISA RABASCA

Monitor staff

Even the most seasoned practitioners have difficulty listening to their clients' accounts of sexual abuse, racial violence or other traumas. In fact, many therapists believe that minimizing their own response is necessary to prevent burdening or overwhelming the patient.

But that strategy may backfire and impede therapy, according to "Countertransference and the Treatment of Trauma," a new volume from APA Books. Clients may misinterpret practitioners' silence or minimal reaction to mean that their providers doubt their stories, are ashamed of their actions or don't want to discuss the topic.

Nonreaction, says author Constance J. Dalenberg, PhD, signals to the client that the trauma is unworthy of attention or that the therapist is uninvolved or uncaring.

The solution, says Dalenberg, is for clinicians to use their countertransference to understand and facilitate the therapeutic process.

"Practitioners need to help their clients understand how emotional reactions to trauma impact the therapeutic relationship," says Dalenberg, director of the Trauma Research Institute in San Diego. "Clinicians need to help the client to understand that shame and anger are normal responses to the reality of trauma. Judicious disclosure of countertransference is one route to clients' understanding and acceptance of their own reactions."

Part of APA's Practical Psychotherapy Practitioner Resource series, the book unravels the complicated relationship traumatized clients share with their providers, combining empirical literature on countertransference with information Dalenberg obtained from in-depth interviews with 84 patients treated for trauma.

Clients Dalenberg interviewed said they could sense the practitioners' discomfort because at times they avoided, misheard or minimized what clients said about their trauma, often without realizing or acknowledging it. Patients reported that they found their practitioners' denial of emotional distress annoying, humiliating and devaluing.

"The therapist often feels the client doesn't want to talk about the trauma, and the client often feels the therapist doesn't want to listen," she explains.

In many cases, both client and practitioner blame the client for the lack of rapport. But typically the problem is neither person knows what to say. One solution, Dalenberg says, is to discuss with the patient the inadequacy of speech, not the inadequacy of the speaker, when discussing a traumatic event.

"Both the client and the therapist would be helped if they discussed the difficulty they're having giving words to events that are outside our general understanding of how life should be," she says.

The book also explores other aspects of the relationship between therapists and clients in trauma, including the reasons why trauma patients often ask their practitioners whether they believe their stories.

"'Do you believe me?' can be a sign that the therapist seems to be distant after hearing about trauma, and given the lack of connection, the client is thinking the therapist might not believe in the severity of the patient's trauma," she says.

The question can also mean "Tell me I'm not crazy," because many trauma patients have chronic doubts about the reliability of their own perceptions of their traumatic events.

Dalenberg also offers suggestions for helping trauma patients end therapy. "Clients complain that they don't know what the endpoint is supposed to look like and feel like," she says. "They can terminate early because they have unrealistic expectations or they can hang on for years hoping to get to a point when the traumatic event no longer makes them sad, anxious or gives them pain."

Dalenberg hopes the book will give practitioners pragmatic examples to help them recognize their own countertransference reactions and discuss these difficult issues with their clients.

"The countertransference reaction can be a major obstacle to treatment success," she says. "But the manner in which we deal with that reaction also can be a major benefit to therapy, and may in fact be the route to treatment success for the resistant and chronic trauma patient."