Group Psychotherapy for Psychological Trauma
Robert Schulte, MSW, CPG
Robert Klein, PhD, CGP, FAGPA, and Victor Schermer, MA, CGP, come from a combined object relations and self psychology approach to group psychotherapy which now overlaps with the “relational” perspective. In their clinical work, they became convinced that in addition to deficits in object relations, a large number of their clients had been exposed to traumatic realities. Authors of ??Group Psychotherapy for Psychological Trauma??, they talk here on the subject.
Schulte: For over 100 years, psychological trauma has been theorized, debated, and revised. Where we are today?
Klein: We are witnessing a resurgence of interest in this area with increasing numbers of basic and applied research studies, clinical accounts, and theoretical contributions. Recent studies identify up to 40–60 percent of patients as having histories of trauma. Furthermore, clinicians are becoming sensitized to exploring more carefully the role and significance of trauma not only in cases involving post traumatic stress disorder (PTSD), but also in connection with depression, substance abuse, and severe personality disorders.
Schulte: If every great enterprise has a third rail, what would it be in the trauma treatment field today?
Schermer: There are two very sensitive areas. One is the validity of traumatic memories. Trauma tends to generate thinking in extremes. We advocate a balanced, sensible approach to the issues by not pre-judging a particular traumatic memory as true or false, but instead waiting for the data to come in, not placing blame, and seeking understanding. It is essential for the therapist to remember all disclosures are part of a here-and-now narrative. The other sensitive area is confidentiality. Each clinician and group arrive at a workable set of policies that fits their needs. The development of merited trust in groups overcomes some, if not all, obstacles to disclosure.
Schulte: Are there common crossroads for therapists of all orientations in dealing with trauma in groups?
Klein: We firmly believe, no matter the particular theoretical orientation, fundamental considerations underlying effective group psychotherapy for trauma include creating and maintaining a climate in which members can feel safe and begin to trust each other. Certainly common crossroads for every group include helping members fully join the group and emerge from isolation, trust each other; experience feelings, find his/her own voice, and be heard, supported, valued, and respected. Ultimately, groups offer a place where members can restore a sense of personal dignity and mastery to develop, transform, and sustain healthy interpersonal relationships.
Schermer: The operative word is relationships. Many trauma specialists unfortunately just treat PTSD symptoms—an important task, but not sufficient. The damaged relationship matrix arising out of trauma is the neglected source of ongoing suffering. Andreas von Wallenberg conceptualized the “internalized holding group,” as the inner representations sustaining our interpersonal lives on a daily basis. This holding group is often devastated by trauma. There is no better place than the community context in therapy groups to heal the life sustaining internal and external object relations of traumatized persons.
Schulte: What dilemmas are created by mistrust as a trauma response?
Klein: The issue of restoring trust is clearly at the heart of successful long-term treatment for trauma. Patients with trauma histories suffer from disturbing intrusive symptoms and experience significant erosion of trust in significant others, and even, in some cases, of life itself. They come to see the world as a dangerous place where their very survival is threatened. The challenge for the therapist is to create a healing matrix, where patients can risk exposure so as to restore a sense of self worth, feel safe, and feel connected to others. Therapists help to reestablish trust by exercising careful judgment in selecting and composing groups, establishing a clear group structure and contract, and paying close attention to boundaries and boundary violations while presenting themselves as steady, reliable and accepting role models willing to examine patients’ painful narcissistic wounds as well as their own inevitable failures of attunement in the group process.
Schulte: Are there any movies or books that capture some of these essential features of trauma work?
Klein: Samuel Beckett’s Waiting for Godot represents themes of emptiness, hopelessness, powerlessness, sadomasochism, absurdity, and disappointment in relationships; and Conrad’s Heart of Darkness identifies the encounter and struggle with the primitive parts of ourselves and the human experience in this work.
Schermer: The Night Porter highlights the essence of re-enactment and repetition compulsion in trauma and the victim/victimizer relationship. The film also shows an interplay of two cultures since it is about post-World War II Germany/Austria and directed by Italian born Liliana Cavini. The movie Shine gives a powerful sense of trauma passed across generations and the struggle of the child of a survivor to have a healthy sense of relatedness.
Schulte: What are your thoughts about the risk of vicarious trauma? Doesn’t that make self-care of the therapist vitally important?
Schermer: Self-care by the therapist is a greatly neglected and crucial aspect of clinical practice. Becoming traumatized as a result of learning about or witnessing someone else’s trauma is inevitable in this field. In groups, it often results not only from what members disclose, but also from what they project transferentially into the group, each other, and the therapist. Burnout happens under cover. The therapist, therefore, must take special care to address his/her vicarious traumatization by identifying it early, transforming it into personal growth and healing, and using it as informative countertransference to identify traumatic re-enactments in the group. I found that in addition to supervision and my own therapy, I needed to develop a personal support group of friends and colleagues. I also find the use of stress management techniques in my daily life as indispensable, not optional.
Klein: There is no question this kind of work takes the therapist into deep water. Maintaining a balance between personal and professional life is critical for a therapist’s self-care. I allow time for family and friends, pursue interests and activities that provide enjoyment and renewal, exercise regularly, watch my diet, and take vacations. This year, I reduced my workweek with patients to four days, and it feels so much better!
This article was published in the August/September 2001 issue of The Group Circle. It originally appeared in the Mid-Atlantic Group Psychotherapy Society Newsletter, Spring 2001, and was reprinted with permission.