In a crude way, I think I have been caught within the divide that Candace Orcutt describes very well in Trauma In Personality Disorder. For many years, while working in the field of substance abuse, I was assimilated into a clinical milieu that prioritized character work, more or less, while ignoring trauma work. Then, during the early part of the last decade, I was awkwardly moved to take the level I training for EMDR, the first third of which resembled a late-night infomercial. It was a heady atmosphere, with therapists and social workers enthusing over the prospect of diminishing symptoms in five sessions or less.
Orcutt’s wonderful book is helping me melt the uneasy feeling that these two realms—character and trauma work—are mutually exclusive goals. No one ever said so directly, nor have I ever put that belief into words. But it’s been in the dialectics, somehow: the discussions between professionals working in teams, or voices heard at conferences, case presentations. Someone will speak of the need for boundaries, limit-setting with a patient, and on cue, someone else will counter with reminders about past traumas, the need for empathy and patience, as if these concepts were all at odds with one another.
I think it’s the same for readers of my novel, Crystal From The Hills. My protagonist, Chris Leavitt, doesn’t readily inspire empathy, largely because his characterlogical defenses (drug abuse, acting out, denial and regression) dovetail with dissociation, creating an aloof, if intriguing figure; a man who is difficult to reach, feel into.
I appreciate the breakdown of technique into the five steps: functioning, containment, strengthening, Cognitive and behavioral change, and insightful and dynamic change. There’s a common sense approach here, above all: the patient’s functioning, their surrounding circumstances, provides the “holding environment” for the work. An assessment of such circumstances is where the work starts. Secondly, containment: therapy draws attention to acting out, denying, blaming, substance abuse and other addictions, and the destructive consequences. In strengthening, a consciousness awakes, an afflicted individual starts to take responsibility; a therapist informs that setbacks may happen as a matter of the therapeutic process, or teaches relaxation techniques. The therapist doesn’t rush to provide insight ahead of the patient’s readiness. The patient realizes that the process of individuation occasions anxiety and sadness. Orcutt appears to paraphrase abandonment depression as part of trauma work.
I appreciated Orcutt’s examples of confrontation of particular defenses. Most are readily understandable. It is even helpful to have each defense assigned a distinctive look and sound. The art of writing is to make ideas seem simple; the technique effortless. I know it isn’t. In the technique that is outlined here, the palette of interventions is widened. Therapeutic neutrality is flexed, and supportive comments and confrontations seem to live together in a therapeutic style. The case of Mrs. X called for many skillful interventions: confronting avoidance (p. 53, 55) and sustaining the thought as she defended against insight. Excellent. Integration is followed by a supportive comment from the therapist, a reminder that trauma distorts time, but that threats are no longer in the moment. Nicely illustrated. The case gets more vivid as Mrs. X becomes more anxious, starts calling the therapist in off hours, with panic about paralysis in her wrists, the fear that she is being held down. She abreacts. The therapist does some reality testing, followed by reassurance, encouragement. Reading this made me nervous, I have to say: this sounds draining.
Yet the acting out isn’t done. Upon calling for hypnosis, Mrs. X “learns” of her father’s sexual molestation of her, and considers legal action, which would be undermined by the hypnosis, actually. In anger, she turns upon the therapist, who becomes a stand-in for a negligent mother. Like Chris Leavitt, perhaps, she is fascinating and disturbing all at once.