Submission to The Social Lens: A Social Work Action Blog submitted by Catrina Brown, Associate Professor, Dalhousie University
Critical clinical work focuses on making sense of people’s struggles and adopting a relational and collaborative approach to the clinical relationship. As practitioners, we have too often pathologized the very behaviours that have helped people to survive. A social justice framework to trauma allows us to address themes of power, betrayal, self-blame, and stigma as critical components of complex trauma work (Burstow, 2003). Women who have dealt with complex and often lifelong experiences of abuse are often labelled, pathologized and diagnosed as having “borderline personality disorder” while receiving little psychotherapy or support for their history of trauma (L. Brown, 2004; Cermele, Daniels, & Anderson, 2001; Herman, 2015; Marecek & Gavey, 2013). Their experiences have often not been heard and, importantly, many if not most relationships have let them down. Little effort is made to see why they struggle so hard to be in the world.
Trauma work requires an appreciation of the dangers of speaking in a culture in which violence against women and children often continues to be normalized and minimized. Too often the legacy of the abuse is reflected in their dominant story and conclusions that they are unworthy and unlovable. They often continue to see themselves as the problem. The “personal is political” approach seeks to make sense of rather than pathologize women’s responses to trauma and violence by listening to and hearing women’s stories. In this process, we need to reframe “symptoms” as “coping skills” and avoid viewing trauma as a disorder, but instead as “a reaction to a kind of wound” (Burstow, 2003, p.1302).
Working with Complex Trauma-Addressing Relational Injury
Relational injury is a common effect of trauma and it has an impact on people’s ability to have satisfying and supportive relationships (Herman, 2015). I will emphasize that the therapeutic alliance is at the heart of doing trauma work with women, especially those labelled “borderline.” Through a case example I will illustrate how difficult it often is to tell one’s story, and the centrality of the therapeutic relationship between client and therapist when working with chronic multiple childhood traumas that have a significant and ongoing effect on living one’s life as an adult.[1] In Violet’s case, she is absolutely certain of the abuse—there is little minimization, little forgetting, but talking about it is painful and at times uncertain. Although Violet does not minimize the violence, it had become completely normalized in her life. She came to believe she had somehow caused the abuse or that there was something wrong with her due to the repeated and ongoing experiences of abuse.
Violet’s struggles have arisen from a complex and long-term experience with childhood trauma. Research clearly demonstrates that trauma, particularly childhood trauma, is associated with a mental health, health, and substance use problems. The development of binge eating, body-image issues, use of alcohol, depression, and suicidality in Violet’s adult life appeared to be a direct result of trying to cope with the consequences of the trauma. In Violet’s story, as in the stories of many women who have experienced significant trauma and abuse, effective therapy and supports often take long periods of time, particularly as developing bonded, collaborative therapeutic relationships takes time and is arguably critical to this work.
Through talking about working with Violet I will emphasize the importance of carefully attending to conflicts between the therapist and client to avoid thickening the relational injury that resulted from her experiences of abuse (Herman, 2015). The conflicts, difficult conversations and struggles that emerge in a strong therapeutic alliance are important entry points for addressing her relationship with herself and others. Also through the therapeutic relationship, a counterstory can emerge which challenges the expectations that Violet may have of relationships.
Violet
As a child, Violet was abused by her father, grandfather, two uncles, and two brothers from the age of 5 to the age of 18. She described herself as the “house prostitute” and said that her bedroom was a “revolving door.” Her mother was emotionally and physically abusive to her. At the same time, the family was well-respected in the rural community. When I first met Violet, she was 26 years old, timid, very quiet, and afraid to speak. She seemed wounded and very vulnerable. This is not necessarily a common presentation of self, but it was notable in her case. Violet had been diagnosed as “borderline,” as so many women who have experienced tremendous childhood trauma and abuse are. She often thought of suicide. She had few friends and as she was estranged from her family, she had no family support. She did have a few key support people in the social service system.
Relational Injury: The Hug, My Cat, and The Drawing
Violet was referred to me from a feminist sexual assault and abuse organization. Violet reported to me that she had been diagnosed as “borderline” and that her psychiatrist had said that she did not have the ego strength to take part in a sexual abuse support group. He indicated he would not continue to see her if she participated in the group. I supported her choice to be in the group and communicated that I thought it would be helpful.
Following a strong first session where initial rapport was developed and Violet shared an initial brief account of her life, we agreed to meet again. My intention was to be as honest and transparent in our work as I could to help establish trust and a strong therapeutic alliance. I observed in the session she was very vulnerable and easily hurt, and I anticipated that she might be sensitive to feeling rejected and abandoned. I suspected this would be a central theme in our work together and believed I needed to communicate that I was competent, trustworthy, and would not shy away from difficult conversations. Through three examples, I will illustrate how important it is not to avoid potential conflict or discomfort; in Violet’s case, they often offered important entry points into her life experiences.
The Hug
At the end of the appointment, as we were approaching the door, Violet asked me if she could have a hug. I understood this would be meaningful to her and may further establish our budding connection. I also sensed if I did not hug her she may have felt I was rejecting her. Despite this, something held me back. I was uncomfortable as I felt I had to hug her so she wouldn’t get upset. It hit me that if I felt this way, I could not hug her as it was the worst message to send to a woman whose whole life had involved invasions of her physical boundaries. On the surface, not hugging her seemed like a bad way to start. However, I paid attention to my “countertransference.” I said gently and calmly that I have a policy of not hugging my clients because so many have had their boundaries violated and I want to ensure that physical boundaries are really clear in our work. Violet was fighting back tears.
I then said, “Violet, I have really enjoyed meeting you today and I think we can do some really good work together. I agree with you about the importance of addressing your history of abuse. I really hope that you understand me not hugging you is not about you. I really want to see you again.” She smiled, a small brief smile. I waited to see if she would come again and she did. After checking in with her, I went back to “the hug” and debriefed how she had experienced this rather than avoid the conversation. This was an important entry point to frame expectations for our relationship. I took the opportunity to say to her that sometimes in our work together, things like this might come up and that even though it is hard, it is important that we can talk about it. I tried to communicate in a respectful manner that although some of these conversations are very hard it is very important for us to be honest and straightforward with each other.
My Cat
Another example involved Violet smacking my cat with a piece of paper during a session. I said to Violet, “Violet, I notice you are hitting my cat, I know it doesn’t hurt her, but I am wondering what is going on?” Her response was, “That cat gets more love than I ever did.”
Rather than avoiding conflict, raising this issue was a critical entry point into talking about how painful it was to feel that my cat had been loved more than her, her anger about that, and to generally explore her experiences of love, and her desire to feel loved. Needless to say, this was a very important conversation.
The Drawing
Telling one’s story of trauma is often experienced as dangerous (Brown, 2018). There is so much at risk. In the process of remaining silent, women’s voices are often rendered invisible. Often women speak with uncertainty or great difficulty. Arguably, a strong and safe therapeutic alliance may help facilitate the finding of one’s voice. Violet asked me to retrieve a book of her drawings that I had been asked to keep safe. These were drawings of her sexual abuse. All these drawings had one thing in common: Violet did not have a mouth in any of the drawings. Violet wanted me to retrieve the pictures because she wanted to draw a mouth on the pictures.
She did not want me to destroy the original pictures in any way, so I suggested I photocopy the images. I gave her pencil crayons and crayons to pick from. She sat on the floor and examined the pictures. She said she wanted to draw a mouth that was not too sexual. We spent some time talking about what colour the mouths should be so they would not seem to be too sexual. After some thought she told me she was going to draw mouths on her pictures that were open, but only a little, and that were purple, not red.
She purposely went about reimaging—indeed restorying—these images, drawing semi-open, purple mouths on every drawing. She was taking charge of how she was going to continue trying to voice her story of abuse and trauma and of their effects on her life. As she finished drawing the mouths, she looked up at me with tear-filled eyes and tears fell down my own cheeks. I was aware of how powerfully connected we were in that moment. I wanted to genuinely show her how moved I was so I did not hide that I was crying. I gently said to her, “This is an incredible thing you have just done.” She was nodding her head. “You have reclaimed your voice.”
References
Brown, C. (2020). Feminist narrative therapy and complex trauma: Critical clinical work with women diagnosed as “borderline”. In C. Brown & J. MacDonald (Eds.), Critical clinical social work: Counterstorying for social) justice (pp. 82-109). Canadian Scholars’ Press.
Brown, C. (2018). The dangers of trauma talk: Counterstorying co-occurring strategies for coping with trauma. Journal of Systemic Therapies, 37(3), 38–55.
Brown, L. (1992). A feminist critique of personality disorders. In L. S. Brown & M. Ballou (Eds.), Personality and psychopathology: Feminist reappraisals (pp. 206–228). Guilford Press.
Burstow, B. (2003). Toward a radical understanding of trauma and trauma work. Violence Against Women, 9(11), 1293–1317.
Cermele, J., Daniels, S., & Anderson, K. (2001). Defining Normal: Constructions of race and gender in the DSM-IV Casebook. Feminism & Psychology,11(2) 229-247.
Herman, J. (2015, 2nd edition). Trauma and recovery: The aftermath of violence—From domestic abuse to political terror. New York: Basic Books.
Marecek, J., & Gavey, N. (2013). DSM-5 and beyond: A critical feminist engagement with psychodiagnosis. Feminism and Psychology, 23(1), 3–9.
[1] See Brown, C. (2020). for a more extensive coverage of this case.
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