By Janelle Kwee.
Carolyn: A Case Study.
Carolyn is a 39 year old woman who sought counselling to address the physical and sexual abuse she had experienced as a child. She had been repeatedly sexually molested between the ages of 8 and 12, by a neighbor and scolded violently by her parents when she refused to go to his house. Until recently, Carolyn had believed that “the past was in the past” and had put her energy into her education career. Carolyn had built a life of professional and financial stability but had few close friends. Two years ago, Carolyn pursued dating through an online service, and has been in a serious relationship for the past six months. As the possibility of marriage entered this relationship, Carolyn has found herself haunted by her past trauma. What she thought would be magical about “falling in love” has instead felt like a “falling out of control” and she has started to have nightmares and flashbacks of sexual abuse. While Carolyn wants to have a future with her boyfriend, she finds herself pushing him away. She fears that she will not be able to have a fulfilling relationship, and is worried that her turmoil will destroy her work, which is the one area of her life over which she has maintained control.
 “Carolyn” is a composite case representing details merged from various clients; in every way; in every way, I have tried to accurately and realistically portray the themes and experiences of real clients while protecting their identities.
The Problem of Feeling Unsafe
Clients like Carolyn sometimes become “triggered” by the very space in which they seek healing. Although Carolyn identified wanting to address the impact that childhood abuse had on her present life, she was surprised that talking about what had happened so long ago flooded her with feelings of helplessness and panic, similar to what she had experienced as a child. Carolyn reported that she had started to have disabling panic attacks the day before each session, resulting in her leaving work early and falling behind on deadlines. This exacerbated her feeling of being out of control and she felt weak and ashamed. She described tension all over her body and was visibly agitated.
While Carolyn’s overarching therapy goals touch on questions of love and intimacy (FM2), identity (FM3), and future life direction (FM4), she immediately faced the question of whether it was possible for her to be, and to be here, the questions of the first Fundamental Motivation (FM1). Carolyn suddenly felt catapulted back to the feelings of terror she felt as an eight-year-old, overpowered by her abuser and shamed by her parents. When she felt dizzy, short of breath, her heart racing, and the intense urge to run away, it was as if Carolyn was in a time warp, unaware of having grown up to be a capable adult.
What is Trauma?
Trauma has been conceptualized in various ways. The Diagnostic and Statistical Manual, 5th edition (APA, 2013), defines a traumatic stressor as “any event (or events) that may cause or threaten death, serious injury, or sexual violence to an individual, a close family member, or a close friend” (p. 830). Briere& Scott (2012) have expanded the description of trauma to encompass events that are traumatic but not life-threatening (p. 14), and trauma researcher Bessel van der Kolk (2006) describes trauma as helplessness combined with abandonment (p. xxi).Traumatic memories are stored primarily in imagery and bodily sensations and lack integration into a cohesive autobiographical narrative. This results in the destruction of an integral whole of one’s sense of self, feelings of safety, and ability to trust self, other and the world (Längle, 2015).
Carolyn’s case illustrates the importanceof safety in the psychotherapy room for survivors of trauma. Her body alarms signaled danger, and although she explicitly trusted in me by seeking therapy, she struggled to let me encounter her vulnerability. To proceed with therapy, it was clear that we would need to orientaround the here-and-now, her body, within the present space and therapeutic relationship. She would have to be able to find her personal “yes” to the question, can I be (here)? Initially, she was in the room but had the urge to flee. To be able to affirm that she can be here, she needs to ask if she has the necessary space, protection, and support. Will she be protected and feel “held” in our work together? Does she experience a sense of embodiment and freedom to take up space in the room?
Cultivating Felt Safety in the Psychotherapeutic Process
The question of the first fundamental motivation is, can I be? Given the impulse to flee, one has the feeling of not being able to be. It is through active dialogue between one’sinner capacity and conditions of the world that one can affirm “I can.” “I can’t” is characterized by powerlessness; it is threatening, blocking, and overwhelming.“I can be here” refers to two parts: (1) I can; and (2) be here. There is an outside world to be in, and inwardly, one hasthe ability to be in it. Being is also tied to a place, here.“I can be here”emergessimultaneouslyfrom the inside and from the outside.
When trauma survivors like Carolyn re-experience feelings of terror and have the urge to flee, we have the opportunity to stimulate their awareness of their inner capacities and outer conditions.
Common approaches to trauma psychotherapy include a tri-phasic process, including (1) Safety, (2) Trauma Processing, and (3) Reconnection (Herman, 1992). I describe below several ways in which therapists can help clients access their own sense of freedom and safety to be in the therapeutic space, to experience embodiment, and to be with their therapist relationally. This provides the foundation for therapeutic work around trauma. These strategies, focusing on being here, being embodied, and being with, pertainto the first phase of safety.
When I meet with someone like Carolyn, I draw her attention to the space we are in. I describe the room as a safe place where I am here to support her, and she is invited to be. I make calming sensory activities, such as playdoh or sandtray, available. When a client experiences flashbacks or somatic hyperarousal, I draw her attention to the present with multisensory cues. I often use an awareness of smells with candles or aromatic herbs. The sense of taste can be invoked with a strong flavor such as a dried clove. If clients experience somatic flooding while doing a meditation or mindfulness exercise with their eyes closed, I have them open their eyes to reconnect visually with the present time and place. I also engage clients in connecting to the present through sensory activities, or by drawing their awareness to the support of the chair.
Our bodies provide us access to the world and to our inner experiences. It is in our bodies that we exist, and only in our bodies that we can be here. When a client like Carolyn is re-experiencing the helplessness, terror, and panic associated with being traumatized, her body is voicing the feeling that it feels it cannot be here. There is a disconnection, blockage, and loss of freedom. The therapist who is attuned to the client’s experience of being overwhelmed in her body will use the opportunity to cultivate dialogue, awareness, and empowerment of the client within her own body. Helping the client pay attention to his or her body, the body’s capacity and vitality through breath work, awareness and acceptance of what is experienced, and guided relaxation, all ways to stimulate a client’s awareness of being embodied, and taking up space in the room. There are many useful scripts for therapists to guide clients into awareness of and dialogue with their bodies, inviting them to a fuller embodied presence in the room, allowing them to experience their ability to invite a calming nervous system response. For clients with chronic somatic hyperarousal, I often begin sessions with guided relaxation or body awareness.
While some clients have success practicing body-based relaxation at home, clients often report that they could not repeat the exercise in a way that was helpful. This highlights the third avenue through which I attempt to facilitate a client’s felt experience of safety: the relationship and energetic connection between the client and myself in the therapy room. My own feeling of calm and ability to support and hold the client in her feelings of terror is conveyed in my body energy, my voice, and my presence. In the context of a secure relational connection where the therapist does not experience feeling flooded or overwhelmed by the client’s panic and fear, the therapist is able to offer relational conditions of safety. When the therapist exercises her own freedom in affirming “I can be here,” and “I can be here with you,” she offers a bridge towards the client’s ability to feel safe in the counselling room.
Janelle Kwee, Psy.D. R.Psych.
Trinity Western University, Langley, BC
Sociedad de Análisis Existencial de Canadá, Vancouver, BC
ARTICLE: CAN I BE (HERE)?: CULTIVATING SAFETY IN THE COUNSELLING ROOM FOR SURVIVORS OF TRAUMA