Author: Perlman, Stuart D.
Publisher: Jason Aronson, 1999
Reviewed By: Gregg A. Johns, Fall 2003, pp. 45-46
This work provides a personally courageous and introspective assessment of the interactions between therapist and patient when confronting trauma and sexual abuse. Dr. Perlman is forthright in discussing the thoughts, emotions, and self-revelations of repressed trauma that may arise for the therapist when encountering countertransference with patients. For the seasoned therapist, this work provides self-validation in managing the stress and ethical dilemmas associated with the treatment of traumatized patients. For the student and novice, it provides guidelines and preparation for what he or she will likely encounter as a therapist.
The text is presented in three major sections. Part I: “The Therapist-Patient Relationship” begins with an overview of dissociation and countertransference from theoretical writings and clinical findings of psychoanalytic and psychodynamic pioneers. The importance of dissociation as a prominent coping mechanism is explored through both historical writings and modern considerations. Early on, Freud and Janet, through their studies with Charcot, observed the dissociation of trauma patients manifesting symptoms of conversion hysteria. Perlman primes the reader with these and subsequent writings by Ferenczi, the British School, and those of American, self and interpersonal psychologists. From here, Perlman describes the initiation of therapy and the progression of the process. This primer provides a backdrop for sparking self-assessment by the reader when processing feelings and reactions to uncovered traumata revealed by the patient.
Perlman’s descriptions of the therapeutic process with his case examples resounded memories for this reader regarding the symbolism, behavioral manifestations derived from trauma during pre-verbal development, and the roles of the therapist elicited by the patient (i.e., “the rescuer,” “the deputy,” “the aggressor,” etc.) during play therapy. The text also provides a thought-provoking discussion of how the therapist’s own childhood trauma and his or her former role of calming a dysfunctional parent leads to the making of a therapist. This is another reason why the opening of trauma states in the patient can simultaneously open up the therapist’s own repressed trauma. The importance of analysis or ongoing collegial consultation for the therapist cannot be over-emphasized when he or she is engaged in long-term therapy with trauma victims. Perlman eloquently and openly discusses his own process of self-exploration in tandem with his treatment of difficult cases. He points out that often the therapist and patient are reliving their respective traumas at the same time. The needs of the patient accompanied with intense emotions can interact with the trauma experiences of the therapist.
Trauma patients can present with a plethora of challenging symptoms including repetitive memories, flashbacks, emotional numbing, omens of trauma, misperceptions of re-experience, denial, self-hypnosis, dissociation and rage. Co-occurring and self-defeating coping behaviors may include substance abuse, self-mutilation, sexual and emotional enslavement, withdrawal, masturbation, adrenaline addiction, suicide attempts, and clinging to other people. Perlman points out some patients may attempt to use therapy as another maladaptive coping strategy. Often the therapist must perform the role of emotional soundboard for the patient’s transference and manage his or her own emotional roller coaster through countertransference.
Part II: “Openings to Trauma and Pain” addresses the emergence of recovered trauma material during the therapy process following initial rapport building. Perlman emphasizes the importance of safety and connection for the patient as preparation for delving into repressed painful material. “Here the patient needs a deep, close experience of the therapist as a good containing other, and even a sense of positive merger or connection” (p. 76).
Perlman indicates how these observations are synonymous with the concepts of traditional preoedipal transference and those proposed by the self-psychologists. The necessity of achieving this goal for therapy is underscored in order for deeper trauma work to occur. Procedural memory (nonverbal memory) also plays an important role in providing openings to the unconscious, more dissociated self of the patient. These experiences occur prior to the child’s development of stable language. The adult patient may initially recall these experiences in bodily sensations such as pain, prior to being able to recapitulate them into concrete memories with verbal descriptions. These volatile emotional displays can be harrowing for the therapist and may trigger the therapist’s procedural memories or dissociated parts. It is during these times that the therapist is vulnerable to contributions determined by his or her own past and not by the treatment needs of the patient.
Questions that the traumatized patient typically needs answered during the early stages of therapy include: (1) Will you hurt, ignore, or help me? (2) Can I have power over myself? and, (3) Can you hear me? Perlman guides the reader through each of these questions one by one. He vividly illustrates the associated delicate and often emotionally draining process encountered by the therapist. An emphasis is placed on the role of countertransferences. The patient often requires soothing from the therapist in order to develop independent coping for the painful material unleashed through procedural memory. To further quote Perlman: “Also, other people usually have been unwilling to listen and provide support after the trauma, creating a secondary traumatization” (p. 84).
These steps may elicit self-doubt for the therapist as the risk of suicide and the emergence of dissociated ego states can bring further challenges. Additional concerns may include violent aggressive behaviors and child abuse. Perlman recommends limiting the number of traumatized patients for the therapist’s self-preservation. The text case examples illustrate the ethical frustrations which can arise in the form of delinquent payments and/or reduced fees for therapy services and the patient’s sense of entitlement that the therapist owes special allowances for their victimization. These issues may also entail crisis calls to the therapist at all hours, which can strain the family relations of the therapist. Patients need to develop self-management skills to contain unpleasant emotional or physical symptoms. Without attention to emotional and physical regulation, the therapist can actually contribute to an overwhelming therapy process for the patient.
Sexualized behaviors by the patient and the therapist’s vulnerabilities to emotional and physical attraction are explored. The reader is provided with examples of internal dialogue that the therapist must process during the sessions. Steps for maintaining ethical boundaries while exploring the latent meaning of the transference and countertransferences are also suggested for patient-sexualized behavior. In my opinion, this discourse is an excellent resource for guidelines in managing these potential pitfalls while working through this material therapeutically.
Limit setting by therapists is necessary when they feel overwhelmed by the patient’s material. This can prevent retaliatory acting out which may endanger the relationship. Therapists must also manage their potential rescue fantasies, which can inhibit the therapeutic process. Consultations and vacations prevent burnout and other emotional or physical impairments for the therapist.
Second-stage therapy questions include: 1) Can you listen to the trauma and validate me? (2) Am I lovable? –Feeling deep love and bonding (3) Can you see me? – Discontinuous and shattered existence (4) Who is bad and who is the abuser? (5) Is this my body? –Touch (6) Can you believe in ritual abuse? Again, Perlman addresses these questions one by one
Trauma patients need to express their trauma experiences and be believed by the therapist. As sexual abuse and trauma memories are painful, disturbing, and often family secrets, the patient needs to validate that these events actually occurred. It is sometimes easier for patients to think of themselves as crazy, deny the reality of the abuse, or cope with dissociative states than to accept that someone abused them. The patient must also learn to accept that they were victimized and did not deserve what happened to them. This is often made more difficult when the perpetrator was a parent or family member from whom the patient expected love and acceptance. As Christine Lawson (2002) has discussed, the trauma patient’s mother may have a personality disorder, be in denial, and/or may possess neurologically-derived memory deficits regarding her abuses of the patient. The therapist must validate the trauma experience and show acceptance of the patient in the midst of graphic and often disturbing recollections.
Perlman illustrates how the therapist may have to acknowledge dissociative ego states or alternate personalities that emerge during later stages of therapy. One compelling example is a situation in which an alternate ego state expresses anger toward Perlman for failing to acknowledge “her.” The therapist must help the patient achieve a “contained” and reality-oriented state prior to leaving sessions. Perlman cites cases of car accidents by patients leaving sessions in states preoccupied with childhood memories. Perlman describes ways the therapist can help the patient to re-focus on the “here-and-now” at the 5, 10, or 15-minute marks prior to closing a session. He tells patients that it is “time to begin putting away the difficult material for now” and to reorient themselves to the outside world.
Part III: “Emotional Survival” concludes the text with chapters that provide guidelines for assessing false memories and final comments on therapist survival. Perlman presents a communication model and relevant research on criteria for the believability of repressed traumatic memories uncovered in treatment. Analysis of the event itself is presented first, followed by an examination of declarative vs. procedural memories. Research and clinical literature regarding false memory assessment is explored and possible patient behaviors and characteristics typical of genuine vs. false memories are described and compared. Risk management strategies for the therapist are also discussed for the legal and ethical dilemmas accompanying recovered trauma memories.
In summary, this is an excellent book for graduate students and clinicians with limited trauma therapy experience. It provides guidelines and lessons learned by a seasoned clinician and may help to alleviate some of the fears and frustrations encountered by the novice. For the experienced therapist, this text provides self-validation and some degree of comfort in knowing that others are encountering similar transferences and countertransferences. It resounds with the classical wisdom of the Oracle of Delphi, “Know Thyself,” and underscores the importance of analysis and collegial consultation as survival tools for the therapist.