Hillel1 famously asked: 鈥業f I am not for myself, who is for me? If I am for myself alone, what am I? And if not now, when?鈥� As therapists we are not for ourselves alone. But are we for ourselves in the face of our clients鈥� trauma? And what action can we take, now?

The impact of trauma is widespread, pervasive, and profound. People report feeling 鈥榮hattered鈥� broken鈥� wounded鈥� ripped or torn apart.鈥�2 According to Winnicott,3 鈥榯rauma implies鈥� a break in life鈥檚 continuity so that primitive defences now become organized to defend against a repetition of 鈥渦nthinkable anxiety鈥�,鈥� and the encounter with trauma means that people even 鈥榗arry around with them the knowledge from experience of having been mad鈥︹�� (my emphasis).

Through the magic of mirror neurones4 and somatic resonance5 鈥� processes that underlie empathy6 鈥� trauma also affects us as therapists: our capacity to perceive, think clearly, respond and, in particular, take proper care of ourselves. Yet this impact of trauma is readily overlooked. The field of mental health today can be likened to industry in less enlightened times when injury and debilitating illnesses were taken as the norm to be tolerated. Guards on the machines or filters for asbestos dust came only as result of agitation and protest and after much suffering. Today the psychic damage that appears as compassion fatigue, secondary traumatisation and even burnout7 is all too prevalent and all too little regarded.

In organisations, statute and good practice require those in authority to take these risks into account, though experience shows that they are not always as diligent as they might be. Problems of workload, poor support and harsh attitudes from management are often cited. In private practice you alone carry the duty of care. For the brief period of reading this article I recommend that you ruthlessly banish all consideration of your clients鈥� needs and indulge the riskily narcissistic notion that it is you alone who matter. As in the air safety instructions: see to your own oxygen mask first.

This challenge is immediate and serious. There may be practitioners reading this who, when they take an honest and unflinching look at their own wellbeing as if it really mattered, will rightly conclude that they should immediately interrupt their practice to focus on their own needs, or even terminate it. Clients do better when their therapists are in touch with their own vitality, wellbeing and self-worth; confident in their ability to engage with the worst that the client can bring without being damaged, and without giving way to the urge to retaliate.

The core challenge

The core challenge for those who work with trauma is within, as illustrated by this apocryphal tale:

You wake in the night to a cry of distress. Taking your lantern, you go out into the dark streets. You find many in distress. Your offers of help are sometimes rebuffed, sometimes welcomed. You fall into sleep on your return. A pattern develops. Each night you go on your rounds, becoming more skilful at bringing comfort where it is needed, and even developing a reputation for your skill. At length a night comes when once again you wake, ill at ease, and realise that the cry you heard on that first night came not from outside your window but from within your own house. At least you have now developed the skill and understanding to bring comfort and support where it is needed and has been lacking.

In The Haunted Self,8 an exploration of trauma-related dissociation, the authors describe how, under the impact of trauma, we split ourselves into what they term (borrowing from First World War studies of shellshock) an 鈥榓pparently normal part鈥� (ANP) and an 鈥榚motional part鈥� (EP) of the personality. I have come to prefer the terms 鈥榗oping self鈥� and 鈥榚motional or vulnerable self鈥�. The coping self typically has a belief that the emotional self (if acknowledged at all) is a problem to be avoided or suppressed. The emotional self often has to resort to producing psychological and/or somatic symptoms. Most therapeutic frameworks have their own ways of expressing this perspective. It is valuable in work with clients; they get it. It is vital in getting to the root of our own resistance to appropriate self-care.

Consciously to embrace the vulnerable self requires us to engage with 鈥榙readed states charged with intense affects that can potentially traumatically disorganise the self system鈥�.9 These are the effects of the overwhelming and shattering nature of trauma. This challenging encounter must be undertaken. While a solo practice like Paul Gilbert鈥檚 compassionate mindfulness10 can be valuable, current relational approaches suggest that some of us may need help with this: 鈥業t takes two minds to think one鈥檚 most disturbing thoughts.鈥�11 So we may need to look (again) to personal therapy. This encounter with our disowned aspects is the heart of the challenge.

And if not now, when?

The risks of inaction are great to our physical and emotional wellbeing, our intellectual functioning, our capacity for relationship, our sense of meaning and purpose in ourselves and in the world around us.12 If I am for myself, what action can I take?

  • Acknowledge these two parts of yourself: the part that needs care and the part that has the capacity to protect, support, comfort and nourish. Let them enter into a dialogue. Use the labels and methods that feel comfortable.
  • Separate home from work, especially if home is where you work; with physical distinctions if you can, with ritual and symbolic distinctions in any case. When you leave 鈥榟ome鈥� for 鈥榳ork鈥�, have an exchange between your coping part and your vulnerable part. Maybe you leave the vulnerable part behind, in an imagined safe place, with a safe person or people, and interesting things to do. Maybe you reassure the vulnerable part that it will not be exposed to the challenging and perhaps frightening emotions that you will encounter while you work. Committing to the dialogue will lead to unenvisioned outcomes and practices that suit you and your situation.
  • When you start work, be ready 鈥� grounded, centred and able to face whatever may arise. Develop a practice 鈥� for example self-remembering* or another form of mindfulness 鈥� for the beginning of your day and of each session.

A personal note

As a teenager I took the Life Saving Bronze Medal training. I learned that when you swim towards a person in distress there is a risk that in their panic they may grasp you so desperately that you both drown. I was taught both to approach with caution and to be ready with vigorous manoeuvres to subdue the 鈥榲ictim鈥� so that I could effect the rescue rather than drown along with them.

For particularly challenging clients, develop an energetic ritual (physical or symbolic) 鈥� some of our students call it a 鈥榳ar dance鈥� or 鈥榟aka鈥� 鈥� that raises your energy level, your feeling of aliveness and presence, and strengthens your protective force fields (cf Star Trek) to the level you need for the encounter. At the end of each session, and certainly at the end of the day, practise a routine or ritual that shakes off or washes away whatever you may have picked up in the day that you don鈥檛 want to transfer from work to home. When you return from 鈥榳ork鈥� to 鈥榟ome鈥�, consciously reconnect your coping part and your vulnerable part.

In private practice you are the boss as well as the workforce. Take time to review the shape of your practice from both perspectives. Consider your workload, the kind and quality of breaks in your working day, the profile of the different challenges among the clients you are seeing. In this process you may have to play the roles of boss, shop steward and arbitrator to arrive at a settlement that satisfies all needs. With these steps taken, review more familiar areas of concern: diet and exercise; recreation and relaxation; time with yourself and time with partners, friends and family; creativity, spirituality, social action; sensuality, play and fun etc. Consider the balance of these things in your life. Plan small steps towards rebalancing. Choose someone to support you and hold you accountable, and begin to take action, recording and sharing the results. Likewise, in your professional life, review the professional support you have arranged: supervision, peer support, plans for further training, as well as looking to your need for ongoing personal work.

Judith Herman sums up beautifully the reward of finding the right balance between service and self-care: 鈥楤y constantly fostering the capacity for integration, in themselves and their patients, engaged therapists deepen their own integrity. Just as basic trust is the developmental achievement of the earliest life, integrity is the developmental achievement of maturity. Integrity is the capacity to affirm the value of life in the face of death, to be reconciled with the finite limits of one鈥檚 own life and tragic limitations of the human condition, and to accept these realities without despair.鈥�13

*Self-remembering14

  • First be comfortable.
  • Next become present.
  • Feel where your weight is supported 鈥� your feet on the floor,your bottom on the seat etc.
  • Let your spine lengthen.
  • Notice your breathing.
  • Look around and name to yourself the shapes and coloursof things you see.
  • Let your awareness expand to become all-inclusive鈥� sensations, smells and sounds.
  • Watch the movements of your mind. Remember your self.

Michael Gavin is a certified Radix body psychotherapist and somatic trauma therapist. He is external clinical supervisor to Transport for London鈥檚 Counselling and Trauma Service and an approved supervisor on the Somatic Trauma Therapy Certification Programme. Now retired from clinical practice, he continues to offer workshops and online training focusing on somatic awareness, self-care for practitioners, and safe, effective work with trauma.

More from Private Practice

Recommended reading

Help for the Helper: The psychophysiology of compassion fatigue and vicarious trauma by Babette Rothschild (Norton 2006)

Compassion Fatigue: Coping with secondary traumatic stress disorder in those who treat the traumatized by Charles Figley (Brunner/Mazel 1995)

References

1. Hillel. Pirke avot 1.14. Charles Taylor (trans).
2. Schiraldi G. The post-traumatic stress disorder sourcebook: a guide to healing, recovery and growth. Los Angeles, CA: Lowell House; 2000.
3. Winnicott D. Playing and reality. New York, NY: Basic Books; 1971.
4. Gallese V. From mirror neurons to the shared manifold hypothesis: a neurophysiological account of intersubjectivity. In: Parker S. Biology and knowledge revisited from neurogenesis to psychogenesis. Mahwah, NJ: L Erlbaum Associates; 2005 (pp179鈥�203).
5. Wooten SD. Touching the body, reaching the soul: how touch influences the nature of human beings. Richmond, CA: Chimes Printing; 1995.
6. Rothschild B. Help for the helper: the psychophysiology of compassion fatigue and vicarious trauma. New York, NY: Norton; 2006.
7. Figley CR. Compassion fatigue: coping with secondary traumatic stress disorder in those who treat the traumatized. New York, NY: Brunner/Mazel; 1995.
8. Hart O, Nijenhuis E, Steele K. The haunted self: structural dissociation and the treatment of chronic traumatization. New York, NY: WW Norton; 2006.
9. Schore A. Affect regulation and the repair of the self. New York, NY: WW Norton; 2003.
10. Gilbert P. The compassionate mind: a new approach to life鈥檚 challenges. Oakland, CA: New Harbinger Publications; 2009.
11. Ogden T. Rediscovering psychoanalysis: thinking and dreaming, learning and forgetting. London: Routledge; 2009.
12. Yassen J. Preventing secondary traumatic stress disorder. In: Figley C (ed). Compassion fatigue: coping with secondary stress in those who treat the traumatized. Florence, KY: Brunner/Mazel; 1995 (pp178鈥�208).
13. Herman J. Trauma and recovery. New York, NY: Basic Books; 1992.
14. http://www.embodiedtherapy.net/self-care

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