CLINICAL PERSPECTIVE:

THINKING BEYOND THE OFFICE

If you can, help others; if you cannot do that, at least do not harm them.

Dalai Lama

Thinking Beyond the Office*

Working as a therapist is always a challenging undertaking. Our clients are complicated individuals, living complicated lives. For many reasons, some related to the therapy process itself and some to social and institutional prescriptions, we usually work in individual offices and our clients come to us. They bring their pain, confusion, and problems with living with them, and expect that we will be able to help them with our knowledge of human psychological functioning, behavior, and relationships.

Because we sit face to face with an individual, or a small group of individuals, our perspective on our clients' lives is limited by the window our clients provide us. We see these lives through the client's words, posture, appearance, mood, behavior, tone of voice - all the things that make up a person's "presentation" at this particular moment in this particular place. We can expand that window by asking questions and by paying attention to the variations and consistencies that emerge in our interactions. To a large extent our skill as therapists is dependent on our ability to create a coherent, accurate picture of our clients from our office perspective and to present that picture to our clients in a way which helps them find new choices and directions.

Our window is also formed by the professional training we have received. While training programs vary by discipline (psychology, social worker, addiction counseling, etc.) and also to some extent within disciplines by theoretical orientation and training philosophy, they share a common emphasis on the individual or the small group (e.g. the family). This training and our ongoing involvement in our profession provide a framework for organizing our thinking about our work; we take in information about our client and arrange it in a way which allows us to relate this person to what we know about people in general, to define the problem at hand, and develop a plan for treatment. Without this framework we would have no way to make sense out of what we observe and no way to decide on one course of action.

Because we are defined as mental health professionals, our training has taught us to relate our particular clients to our body of professional knowledge through the use of diagnostic categories. These categories were developed (at least in principle) to help us identify patterns of behavior, emotions, and thinking which are indicative of identifiable and distinct problems and which can thus be linked to treatment plans which are appropriate for each particular problem.

The general acceptance of a diagnostic framework in our profession has allowed us to share information about human problems and treatment in a common language. Thus, when one professional talks about developing a treatment approach for depression, for example, we know what depression looks like and which of our clients fit that category, which ones might be helped by this new treatment approach. We are not forced to reinvent the wheel each time we work with someone new, and we can decide which information about our new client is relevant to helping this person.

However, like any cognitive framework, this mental health approach must produce order in all this complexity by deciding which information is significant and which questions (and thus which answers) are relevant. In doing so, the approach also defines what information is seen as not significant and therefore ignored, and which questions are not asked, which answers are not heard. This realm of the irrelevant and unseen, however, is usually defined by default (defined by what it is not), rather than deliberately and explicitly. This inevitably creates blind spots in our professional thinking, leading us to miss or discard information which really is relevant and which will affect the treatment we give our clients and thus will affect our clients.

The training manual of which this chapter is a part is intended to help mental health and victim service providers work together toward the common goal of helping individuals who come to either one or both of us. We have been working on how to coordinate our efforts, acknowledging that often neither of us has everything a survivor needs. Since what we each have to offer is different, we use different frames of reference for organizing our thinking about what we observe and for deciding on a course of action. Becoming more aware of the roles trauma and victimization play in our clients' "mental health" can help us see beyond our offices, into territory which may have been defined as irrelevant within our professional discourse but which often holds information which leads to a much more useful understanding. To the extent that understanding the problem more completely leads to more effective solutions, we are likely to be more effective in our own treatment plans and to recognize both the need for and the usefulness of services we do not provide. When we expand our awareness beyond our offices, we can expand our own professional framework, and also avoid the error of thinking all of reality can be reduced to what is known, or even knowable, within that framework.

This chapter will start with certain assumptions or guiding principles based on this willingness to see beyond what is professionally familiar:

• First, we work with people, not disorders. If we forget this, we will limit our understanding of our clients by reducing them to what can be contained within any diagnostic framework.
• Second, psychological, physical, and social factors can only be separated abstractly. In our clients' lives they form a cohesive whole. If we want to be effective we cannot forget these interrelationships even if we only work directly within a psychological perspective.
• Third, we benefit from exploring the territory beyond professionally accepted definitions of relevant knowledge. We can expand our own frame of reference and we will recognize when to make referrals outside our system.

Integrating Awareness of Victimization into Treatment

While most of us are trained to take a psychosocial history as part of the treatment process, often that history is only poorly connected to the diagnosis and treatment plan. Awareness of a past history or the present experience of trauma, abuse, and/or intimidation should have an effect on the way we think about everything we do, and can often mean that the presentation we observe will have a very different meaning and significance than it might in the absence of this history. Unfortunately, all too often the significant integration of the person's past history into treatment decisions is identified with a specific theoretical position (psychoanalytic/psychodynamic). Even when this history is seen as a causal factor in the current "condition," the diagnosis itself and the general treatment plan are often developed solely on the basis of the current presentation and even before any history is taken.

The diagnostic framework within which most mental health professionals work is codified in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). It is intended to provide a set of commonly agreed upon criteria for conditions which can be recognized with consistency and are clearly distinguished from one another. The assumption is that if we can identify a condition accurately we will be better able to differentially apply treatment strategies and techniques, as well as facilitate professional research and dialogue. The DSM's diagnostic categories and the criteria for inclusion in each are deliberately based only on observable signs and symptoms, and are intended to be theoretical, to make no assumptions about etiology, and to avoid being culturally specific.

The usefulness of such a framework is not in question. As a profession we do need to be able to understand each others' references. The DSM categories provide a useful reference point, allowing us to define our areas of agreement as well as disagreement. Even when we do not use this particular conceptual framework in organizing our thinking about our clients, the existence of this "standard" often helps us define our own positions more clearly by having a clear contrasting position and allows us to communicate our position more clearly to colleagues.

However, this professional standard has also been subject to appropriate criticism. For example, the DSM and its categories and criteria are largely the product of a particular subgroup within the mental health field, psychiatry, and are therefore strongly affected by the assumptions and world view of this medical profession. While other professional groups have had a consultative role in the development of the most recent diagnostic system, the farther these groups have been from the medical experience, the less voice they have had. For instance, social workers have not had the influence that clinical psychologists have had, and voices from outside the recognized mental health professions (such as victim service advocates or community advocates) have only had an impact on the process indirectly, and only to the extent that they have been heard by and have affected the "insider" participants in the development process.

This has clearly limited the final product by restricting the information used in creating it to that which psychiatry as a whole considers relevant and with which it is comfortable, most notably the tendency to see human suffering in terms of diseases and disorders of the individual. Thus the diagnostic categories are not organized in terms of "disordered relationship patterns" (which might lead to categories such as "shame-based disorders" or "disorders related to abusive use of power") or painful individual consequences of social and cultural norms (such as "social class related disorders" or "bias and discrimination related disorders"). These would not necessarily be better diagnostic categories, but they would be equally legitimate ones and would lead to the inclusion of information which is dismissed as irrelevant within a medical perspective but which may be equally relevant to the life experiences of our clients.

We also need to be aware that the development of these diagnostic criteria are not even an objective reflection of a unified medical perspective. The field is characterized by a multitude of theoretical perspectives which inevitably means that the final document is going to be a compromise, an attempt to find a framework which is inclusive and which allows for discourse and common definitions across these varying positions. Also, the debate over categories and criteria reflects the pressure of factors which are outside the realm of professional discourse and which are not acknowledged openly in either the categories or the official discussion of the development of the conceptual framework (such as the social and economic interests of the different professions in the mental health field, and the class and power differences between professionals and clients/patients). DSM-IV and all its predecessors are inherently social and political documents, but the effects of these forces cannot be recognized unless we step outside the limited perspective of the field.

In addition, the attempt to provide a diagnostic system which is not limited by cultural factors has produced a document in which cultural variation is acknowledged only in the introduction to the manual. We are cautioned (in the introduction) that these factors must be "taken into account" (although there are no guidelines as to how to do this) and that we should modify our interpretations of clients' reports of symptoms based on awareness of varying cultural meaning systems. The bias toward minimizing the cultural limits of this diagnostic system is shown both in the absence of cultural variations in the diagnostic categories and criteria themselves, and in the inclusion of an appendix titled "Outline for Cultural Formulation and Glossary of Culture-Bound Syndromes" as if the rest of the manual were not a cultural formulation.

What are the implications of these professional realities for our work with survivors? In short, be aware of the limits of our diagnostic system. Respect the usefulness of its potential for organizing our understanding and informing our decisions, but do not confuse it with a complete picture of our clients' lives, or even psychological experience.

More specifically:

• Do a history before you assign a diagnosis. This increases the probability that you will take experiences such as trauma and abuse into account.
• Always be aware that the diagnosis is only a means to an end, that it helps you as a therapist relate your clients' problems to a body of professional knowledge. It is potentially useful for both you and your client, but is not adequate as or a substitute for an understanding of your client as an individual.
• Communicate this limited meaning of the diagnosis to your clients. Allow them to know that the diagnosis is a useful tool, not a description of them as people. Let them know what it tells both of you about the similarities of their experiences to those of other people, and what it does not tell you about the uniqueness of their experience.

• Use the diagnosis as a shorthand description of a collection of signs and symptoms not as a description of or a label for the person. Be careful in your use of words, and not just in front of your client. We aren't working with depressives, or borderlines, or even PTSDs. If we force ourselves to refer to our clients as people with symptoms consistent with depression or PTSD we are more likely to stay aware of the full range of factors affecting their functioning and experience.
• Remember that the context in which signs and symptoms occur affects their meaning and therefore the significance in making a diagnosis. Confusion in the midst of a traumatic experience has a different significance than confusion without trauma. Feelings of powerlessness in the face of real social powerlessness is not necessarily a symptom of a depressive episode.
• Use the diagnosis to identify problems rather than to pathologize the client. This means seeing the strengths and functional aspects of their behaviors as well as the dysfunctional ones. If you identify your clients as dysfunctional you make it difficult for both yourself and them to see their strengths and resources. When we validate the functional aspects of their behavior and the legitimacy of their emotions and needs, we can also identify their problems and dysfunctional behavior in a way which empowers them.

There are several diagnostic issues that are relevant in working with clients who have been abused and/or traumatized. One of these is the use of personality disorder diagnoses on Axis II. Therapists need to be aware that abuse can affect both the way the diagnosis is made and the implications of the diagnosis for treatment. A personality disorder is defined as "an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual's culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time, and leads to distress or impairment (DSM-IV, p.629)."

Because by definition they are characterized by persistent patterns of problematic behavior, it is often easy to see these disorders as inherent to the individuals themselves rather than looking closely at the context in which these patterns developed and are maintained. Abuse in childhood, especially if it is prolonged, repeated, and ignored, can lead to the development of patterns of reaction and behavior which are functional in the context of the limited options open to children but become dysfunctional in other contexts. In addition, these patterns become incorporated into the child's view of the world and to the developing sense of personal identity. The children, and later the adults, make the same error that the therapist can make so easily - confusing the adaptations they have made to intolerable situations with characteristics inherent to themselves as individuals.

Once the personality disorder is equated with the person, the diagnosis can have several negative implications for treatment. In many ways, personality disorders represent extreme manifestations of human emotions and reactions. However, the needs of these clients are often seen as evidence of the disorder. The needs thus become symptoms to be eliminated, whether it be the need to be taken care of (dependent personality disorder), for attention (histrionic personality disorder), or for attachment (borderline personality disorder).

Clients often experience pressure to change as pressure to eliminate the self, and even when they are profoundly unhappy with their current situation, self protectiveness will set up strong ambivalence about therapy. Recognizing that the underlying needs are valid, while clearly acknowledging that the patterns developed to meet them are dysfunctional, allows both therapist and client to identify the client with the underlying human needs rather than the "enduring patterns of inner experience and behavior." In this context, naming the abuse the client has experienced and recognizing the effects it has had can be a powerful way of breaking connection between destructive adaptations and the self. This process can be particularly empowering to clients, since it allows them to see change as taking care of themselves rather than as a betrayal of self.

One other way that the diagnosis of a personality disorder can have a negative impact is that it can lead both therapist and client to focus attention on the client's distorted reactions to events, and thus minimize or ignore abuse or victimization in the present. While this can sometimes be difficult, clients need to be encouraged to recognize abusive behavior and take effective action to protect themselves. Therapists need to be aware that just because a client has learned, for example, to complain constantly (having not been listened to in the past when she stated something was wrong), it does not necessarily mean that there is an invalid basis for the client's complaints. Therapists need to remember that these clients are still vulnerable to abuse and exploitation in the present, and if that is ignored it increases the need to act out their needs in extreme ways.

Some similar concerns arise in using diagnoses related to alcohol and/or drug dependence. Substance abuse often starts as an attempt to self-medicate overwhelming pain. Over time, the person comes to believe that survival depends on using and identifying with the substance use: "this is just who I am; I'm not strong enough to survive without this."

In an attempt to get substance abusing clients to take responsibility for their behavior in the present, many individuals and programs reject any discussion of past abuse (or even present abuse) as avoiding responsibility, denial, or excuse-making. Acknowledgment of their deep emotional pain by these clients is seen as self-pity. However, if the only alternatives given to clients are denial of the addiction or denial of their pain and the real effects of abuse, they essentially have only destructive options - a replay of the situation they've been in from the beginning.

Denial and avoidance of personal responsibility are certainly characteristic features of drug and alcohol addiction. However, one of the difficulties with the diagnosis is that once seen as an addict, everything else about the client may be seen through that filter. A history of abuse and victimization is not less significant simply because the person developed a pattern of substance abuse to cope with the effects. Also, current abuse is not less significant because it happens to someone who is drunk or high. If anything, people who are substance abusing are more likely to be victimized, and the abuse and exploitation may be even more harmful because it confirms the person's negative experience of self and others. To minimize the seriousness of victimization in these contexts is to reduce the person to a diagnosis, to reinforce the sense of worthlessness and powerlessness (as if it's OK this happened to them because they're addicts), and to give the person no constructive way to deal with the effects.

When the seriousness of the abuse is recognized and the reality and validity of the clients' pain is acknowledged, sobriety can be experienced as healing and self-care rather than as punishment. Assuming responsibility for one's own life and behavior can be seen as empowering rather than an admission that s/he has been "acting like a victim." Recovery can and should be seen as a profound act of resistance to the pain inflicted on the person, and in this way it is a refusal to assume blame for the destructive behavior of others. Recovery is also a willingness to assume responsibility for the harm we have done to self and others. Clients must be helped to do both, and the reality of the second should not be allowed to invalidate the first.

Therapists working with survivors (and with any client, for that matter) need to be aware that the potential for abuse and exploitation by others is an ongoing reality for everyone. Survivors may be particularly vulnerable to injury in this way not because they create or seek abusive situations, but because their ability to recognize danger, to be self-protective, and to defend themselves effectively may be reduced as a result of earlier abuse. Clients should be helped to understand this, and recognize their vulnerability so that it can lead to efforts to protect themselves more effectively (empowerment) instead of self-blame and hopelessness.

Many survivors recognize the pattern of repeated trauma and abuse in their lives, and come to see themselves as having been "singled out" for bad things. This leads to a sense of inevitability, as if something about them makes them "magnets" for destructive people. Often therapists make the mistake of trying to undermine this way of thinking by arguing that the survivor is not special in this respect, that bad things happen to everyone. However, this approach may have the unintended effect of invalidating the survivor's accurate perception that victimization has become a pattern and minimizing the significance of the pain that is experienced. Survivors need to recognize and take seriously any abuse or threat of abuse as a first step toward changing this pattern.

• Don't be afraid to acknowledge a survivor's continuing vulnerability to abuse and victimization. What survivors need is the clear message that this vulnerability is in part a negative side effect of earlier efforts to protect themselves from the pain and fear of traumatic experiences and in part the result of the social distribution of power. They can thus be empowered to make changes without blaming themselves for the vulnerability itself.

• Do a careful assessment for current abuse and exploitation, and repeat this throughout the therapy process. Don't assume that if abuse isn't occurring at the time of the initial assessment that it isn't occurring later. Don't assume that your client will volunteer this information, or accurately represent its seriousness.
• Don't accept clients' assessment of danger and/or harm at face value. Survivors, especially those in currently abusive or threatening situations, often deny or minimize danger or injury as a way of managing their own feelings of vulnerability. When clients say that the situation isn't that bad, they may be reporting their assessment of the treatment they deserve or the degree of their emotional numbing more than reporting the actual danger. Ask specific questions, and point out the discrepancies between their reports of actual behaviors or events and their evaluations or interpretations of those behaviors or events.
• Make safety from harm by others a first goal in therapy. In order for survivors to deal with prior trauma they have to begin to believe they will not be overwhelmed by the emotions associated with that trauma. Part of this belief is based on knowing that the abuse belongs to the past rather than to the present. If the survivor is being abused currently, or there is a real threat of abuse, without effective ways to deal with the current situation, the survivor may actually be overwhelmed and therapy will end up confirming all the fears that have held the dysfunctional patterns in place.
• Make referrals and help clients to make use of community resources. As a therapist you cannot protect clients and you should not try. Nor should survivors be encouraged to think they can handle dangerous situations on their own. Know what is available in your community and how to help your clients gain access to these services. (Victim service providers are good sources for this information.)
• Do not encourage clients to make themselves vulnerable in situations in which they really have no control. Do not encourage clients to confront abusive or exploitative people if there really are no effective constraints on the perpetrator's behavior or if the clients really have no way to escape or protect themselves. Do not involve perpetrators in the survivors' therapy if the survivors are still vulnerable to attack or victimization once they leave your office or if you cannot protect the survivors from harm (physical, verbal, or emotional) in your office. This means that most couples counseling in cases of domestic violence or family counseling involving perpetrators and child victims should involve separate therapists for victim and perpetrator, and risks should not be taken with the victim's safety in the interests of a systems approach to family dysfunction.

Self-harm or self-injury/mutilating is often an issue in the treatment of survivors. It is a distressing behavior, often as much or more for the therapist than for the client. Self-injury can take physical forms, such as cutting or hitting, or it can take internal forms, such as internal verbal abuse or the intrusion of painful images or memories. As self-destructive as these behaviors appear to be (and are), they have usually developed as a way of managing even more painful injuries and emotions and are therefore difficult to give up. Clients must be given alternative ways of meeting this need if they are to give up behaviors which have given them at least some protection.

Physical self-injury can be the hardest for therapists to tolerate, and it is easy for them to communicate their panic to the clients. This can both frighten and shame the clients (although this is rarely the therapist's intent), and lead to efforts to hide the behavior to protect or please the therapist. This may make the therapist more comfortable but does nothing to help the clients.

Internal self-injury can be just as self-destructive but is obviously even easier to hide. It is common in survivors and can serve the same variety of functions that physical self-injury does (e.g., self-punishment, either stimulation or numbing of emotions, a trigger for dissociation, reinforcing a sense of control and strength, etc.).

Survivors are often frightened and ashamed of this behavior, seeing it as evidence that they are crazy or bad. Efforts to "control" it by trying to stop usually end in failure, increasing the fear and shame. Survivors often feel sure that if anyone knew they would be rejected, or worse. They usually cannot see the connection between the trauma and the self-injuring behavior, and so it feels like there is no reason for the behavior other than their "craziness" or "masochism."

Self-injuring behavior can be a serious threat to survivors' safety, even when it is not suicidal in intent. When it is used to manage emotions and intrusive thoughts and images, the behavior may escalate dangerously in times of greatly increased stress or crisis. If it occurs in the context of dissociative episodes, survivors may have a reduced awareness of their actual environment and therefore a reduced capacity for self-protective responses. Internal, non-physical self-injury can be equally dangerous. It leads to repeated trauma, with all the negative psychological effects of any trauma. Because it almost always involves a degree of dissociation, it reduces awareness of the external environment and increases the survivor's vulnerability. It may also lead to extremely risky behavior, such as driving in an impaired condition. Therefore the behavior should be clearly and directly approached as a safety issue.

• Do a careful assessment for self-injury, both physical and psychological. This assessment should include both an evaluation of the behavior and an evaluation of the behavior's functions. This is the first step in treatment, and it communicates to the survivor that the behavior is neither meaningless nor crazy.
• Do a careful evaluation for suicide risk as well as self-injury. This will help you distinguish between behavior which is self-destructive in intent and that which serves other purposes but in self-destructive ways. Both are serious problems, but may require different interventions.

• In treatment, focus on finding alternative ways to meet the functions served by the self-injury, not just on eliminating the destructive behavior. This keeps the focus on positive change and allows both therapist and client to build on the survivor's strengths and impulses toward self-protection. Direct assaults on just the behavior almost always lead to failure, frustration, and shame (for both therapist and client) and can severely undermine the therapy.
• Recognize your limits. As with harm from others, the therapy relationship cannot provide a protective cocoon for survivors. Your role is to help them find and use the support systems available.

Medication can play a useful role in the healing process for survivors since victimization and trauma have physical as well as psychological consequences. However, when all painful or uncomfortable emotions are automatically defined as symptoms of a mental disorder, medication may be used inappropriately in ways which actually hinder the resolution of traumatic events. In addition, survivors may be given the message that there is something wrong with them (i.e., they should be reacting differently) when emotions and behavior are evaluated only as symptoms.

Strong, difficult emotions such as sadness, fear, and anger are human responses to painful, frightening events and need to be experienced, identified, and given meaning by survivors. However, if these emotional reactions have persisted over extended periods of time without the survivor having the opportunity to express and understand them, they may overwhelm the survivor's physical and psychological ability to respond to people and events in the present. The distinctions between past and present, danger and safety, abusers and non-abusers can become blurred. For example, the sadness and grief that is an appropriate response to significant loss, if unresolved, may undermine the body's ability to maintain a stable mood and the survivor may become not just sad but depressed.

At such times medication may provide not only relief but may help the survivor sort through emotions more effectively and recognize the source of the original grief. Similarly, chronic hyperarousal may interfere with the body's ability to regulate arousal, and the survivor may experience anxiety and panic that is not clearly connected any more to present events. If the therapist does not recognize the possibility of such physical consequences of trauma, clients may become unnecessarily frustrated and discouraged in therapy.

On the other hand, the current emphasis in much of the mental health field, especially among psychiatrists, on the biochemistry of mood and anxiety disorders often leads therapists to focus on physical symptoms and to label disturbances in mood or emotion as "biochemical imbalances." This often leaves survivors believing that their reactions to abusive experiences and situations are caused by their biological inability to "handle stress." It is too easy to go from this belief to a treatment focus on changing the survivors rather than on helping survivors change their situations, and medication can become the logical way to eliminate or change the survivors' reactions. Within this framework, behavioral, cognitive, and emotional interventions become only additional ways to change a disordered client.

While it is unreasonable to ignore the physiological changes that can and do result from victimization and trauma, there are several ways therapy can become less effective if our perspective on our clients becomes too heavily biological. We can easily collude with survivors' (and society's) self-protective denial about the reality of victimization and abuse, supporting their efforts to minimize the seriousness of the abuse by maximizing their sense of weakness and "dysfunction." We can turn the goal of effective coping into increasing the capacity to tolerate the effects of abuse, powerlessness, injustice, and so on by focusing on managing mood and emotional reactions to events.

If we see human pain primarily in terms of biology, we are also less likely to ask questions about why these clients might have become emotionally or physically overwhelmed. We are less apt to consider the answers to these questions as relevant to treatment, and thus less prone to direct our clients' attention to changing the problems in their lives, or to recognizing the problems in society as a whole. Problematic behavior patterns are also less likely to be understood (by both therapists and survivors) as positive attempts to manage the effects of abuse if the emotional reactions themselves are seen as symptoms of a biological disorder. The strengths and resources (both physical and psychological) of survivors are likely to be ignored or minimized.

Thus, the biological effects of victimization need to be taken into account, and medication may be a useful part of treatment. However, it cannot be the focus of treatment when victimization and trauma are involved without masking the meaning of our clients' emotional responses.

• Evaluate the biochemical factors in your clients' experience only as part of the total picture, so that emotional and cognitive responses are not seen in isolation. For example, a family history of depressive episodes may be important because it helps us understand the way trauma may affect this particular survivor, but it does not make genetic vulnerability to depression the cause of the survivor's problems, nor should it be allowed to distract therapy from trauma issues or to make the survivor's pain seem less appropriate or "unhealthy."
• Medication should be considered when the survivor's depression, anxiety, or other emotional responses overwhelm the ability to protect themselves (from self-harm or injury by others), or the ability to use psychological resources to process the trauma and make constructive changes in the environment. It should not be used to avoid painful emotions in all circumstances because this would prevent real confrontation with the abuse and/or trauma.
• Know your psychiatric referral base. Make sure whenever possible that the psychiatrists to whom you refer survivors are familiar with victimization issues, and are willing to work with you as the therapist providing psychological treatment. Also, make sure the psychiatrists understand the importance of other service providers (such as victim services providers) and are willing to work with them.

The way each individual therapist evaluates the outcome of the work with a client depends a great deal on the therapist's theoretical framework. However, there are some general principles which apply to psychotherapy work with survivors and which cross disciplines and theoretical perspectives.

• The evaluation of outcome always needs to look at the survivor as a whole person. The reduction of painful or uncomfortable emotions cannot be evaluated as positive if abuse or victimization is continuing or if past trauma is still being re-experienced internally. Under these circumstances the absence of emotional pain would indicate that adaptation to the trauma was still requiring responses that maintain your client in a victim position (such as dissociative reactions to abuse or the psychological numbing of depression which would interfere with taking effective action to end the abuse).

• A positive outcome in therapy should include re-establishing survivors' connections to the community. This involves a sense of belonging, of being supported by a network in which their experience is recognized and taken seriously. It also involves a sense of empowerment, of being able to take effective action which has an impact on others. This sense of empowerment incorporates not only an ability to act on their own behalf, but also a sense of commitment to change in their communities, although this commitment can take many forms. A therapist truncates survivors' healing by treating it as only an internal, psychological process.

Therapy in the Context of the Survivor's Life

A therapist working with survivors tries to create a safe space in which survivors' voices can be heard, often for the first time. The therapy relationship and the actual meeting space are thus to some extent protected from the stresses of the "outside." However, the healing process itself is not and cannot be protected in this way. It occurs in the context of the survivor's entire life, and is affected by all the stresses and needs which are part of that life. Therapists must therefore recognize that since healing, rather than therapy, is the ultimate goal, these stresses and needs must be addressed if therapy is going to be helpful to the survivor.

At the same time, however, the therapist's usefulness to the survivor will be reduced if the therapist tries to deal directly with all these issues. The therapist would be taking on more than any one person can do, and therefore inevitably leave too little time and energy for therapy. Also, if the therapist becomes too directly involved in other areas of the client's life, the therapy relationship can no longer be as protected and safe as it needs to be. The therapist needs to find a way to keep therapy clearly connected to the rest of the survivor's life, and at the same time protect therapy's unique place within that life. This necessarily means helping clients find and maintain other relationships in which many needs and stresses can be more effectively addressed.

While the therapist cannot effectively assume responsibility for addressing all of a client's needs, the therapist must know what these needs are, how they are affecting the client's life, and how to help the client address them effectively. Not assuming responsibility for meeting these needs is not the same as ignoring them. One of the most effective links to effective help is the victim services provider, and therefore the active involvement of these provider networks can create a supportive environment for therapy.

Survivors may have any number of unmet needs and stresses which negatively affect the quality of their lives. More specifically, these stresses can undermine the healing process, keep the client locked in a cycle of revictimization, block healthy growth and development, and limit the client's ability to nurture those who are dependent on the client (especially children, who become caught in the victimization process without the ability to act on their own behalf). Basic needs such as food and shelter are often provided by abusers. Even when these are not directly linked to tolerating abuse, the lack of basic necessities, or the threat of losing them, is obviously going to increase the survivor's feelings of hopelessness and powerlessness.

Survivors, like everyone else, also need to know they have access to physical and legal protection from victimization. Unfortunately, the justice system does not have a good record on providing this protection to many of those most vulnerable to victimization. Having an advocate who is familiar with these social institutions and who can facilitate their effective use is often critical, and this advocacy is the role of the victim services provider.

• Be aware of, and help your clients be aware of, needs which you are not able to address directly. Survivors are often not good at identifying these needs, since they may have learned to tolerate or deny deprivation and insecurity in order to reduce pain and anxiety.
• Be aware of community resources and make your clients aware of these. This does not mean you must become the link between the client and these services, but that both you and the client maintain an awareness of the client's connections, or lack of them, to community providers and resources.
• Do not be afraid to facilitate these connections. You do not need to step out of your role as therapist to believe these needs are important and to act in a way consistent with that belief. You can facilitate the survivor's use of community resources by addressing psychological barriers to reaching out to safe and supportive individuals and groups. You also need to recognize that your social position (both personal and professional) may give you more influence and access than your client (e.g., doctors may listen to you more seriously because of your professional status). See yourself as part of this larger social network and participate in it in ways that are useful to your clients.
• Work with your client to find the balance between active collaboration with other service providers and protection of the privacy and safety of the therapy process. This balance will be somewhat different for each survivor. However, it is up to you as a therapist to understand how therapy differs from other helping relationships and to be clear (with yourself and your clients) about what you as a therapist can and cannot do for your clients. You thus communicate that you can be relied on without setting up unrealistic expectations for therapy or setting up other providers as competitors.

When thinking about community resources for clients, it is important not to restrict thinking to social agencies or institutions which are defined as "helpers." Other social institutions and groups, such as churches, unions, and neighborhood groups, can provide important experiences of validation, support, and empowerment. (Be aware that these groups may provide opposite experiences as well for many survivors.) Because survivors have often learned to keep their experiences and needs secret, they may have little practice in matching specific needs with the resources offered by others. They may even have difficulty differentiating among their many needs.

In these circumstances their own neediness and the helpfulness of others may be seen in very black and white terms; dependency/help-seeking jumps back and forth between zero and 100 per cent. Every relationship (sometimes every interaction) can become a test (either consciously or not) of the survivor's own right to need help and/or of the other person's ability to help and be trustworthy. When this occurs, survivors who do risk reaching out often find themselves experiencing repeated disappointment and betrayal even with those who are trying sincerely to help. Learning how to make more differentiated requests for help and to recognize the value of what a particular person has to offer can transform the survivor's life from a series of disappointments into a network of specific sources of support. Conversely, learning to recognize the limits of even the most supportive people can help protect the survivor more effectively from victimization in the future, because trust does not have to be either an all or nothing process.

Understanding the difficulties that survivors often have in differentiating their needs and their trust is vital to therapists working with them. We are much less likely to become defensive in response to our clients' disappointment, anger, and frustration with therapy and with us as therapists if we understand how necessary it has been for them to avoid "mistakes" in trusting or needing others. It becomes easier to communicate that it is safe to rely on us as therapists without getting caught in trying to prove that we will never disappoint or fail them (an impossible task since they have needs we cannot meet).

Recognizing the difficulties involved in learning to trust others in less than black and white ways is also very important if we are going to work collaboratively with other providers and with the survivor's support system. While it is critical to validate the client's experiences of hurt, disappointment, anger, and so on in dealing with the other person, this needs to be done in a way which does not distort the total relationship. Survivors may need help evaluating relationships in ways which take into account both positive and negative experiences. They need to feel empowered to take negative experiences seriously enough to do something about them, but they also need to know that all relationships involve negative experiences and that healthy relationships can deal with hurt, anger, and other difficult emotions. If we as therapists jump too quickly to "defend" our clients and reduce their experiences with others to a defensive black-and-white perspective, we may inadvertently reinforce the distorted view of reality which the original victimization created.

The same principles are involved in helping clients establish a support network among friends and family. If therapists see other people in the survivor's life only in terms of dysfunction or of their potential for harm, then clients are put in a position of either defending them (against us) or becoming isolated from them. Also, by leaving so little room for other people to make mistakes and be imperfect, we may make it difficult for clients to recognize or acknowledge their own mistakes and imperfections without overwhelming shame. This is not to say we should minimize or excuse abusive or destructive behavior, but we need to remember that human relationships should not be oversimplified.

We also need to help survivors learn how to draw the best from the friends and family on whom they rely. Often these supportive people are left floundering in the dark because clients can't explain what they need or what they are experiencing. Survivors may be afraid or ashamed to talk to others, or may just not know how. Therapists may recognize that friends and family are important but often make unjustified assumptions about the way support is available to individual clients. For instance, many therapists assume a survivor's husband "should" be her closest emotional support, when it is often a friend or sister. If a therapist considers involving immediate family members in therapy for survivors, interventions involving significant others with less socially recognized ties should also be considered. The other person may be provided with education and information which would be helpful in the relationship and therefore to the survivor.

Specific relationship problems related to the unrecognized effects of the earlier victimization can be addressed in ways which empower the survivor and also model effective communication. Other people may be able to help the clients identify and use resources available in their social and physical environments of which the therapist is not aware. Helping others who care about the client find ways to effectively provide support is often a great relief to both the survivor and the other people. Also, involving close friends as well as family in the healing process can help break down the isolation created by shame and can strengthen the experience of emotional closeness for both the survivor and the other person.

However, care needs to be taken when involving other people in a survivor's therapy. The therapist needs to consider both the impact on the therapy relationship and on the client's life outside the therapy session. Safety concerns always need to be addressed (see previous section on safety). Also, clients need to feel they have control in the therapy relationship and that others, well-intentioned or otherwise, will not supplant the survivor in the working relationship with the therapist.

• Work with the survivor carefully in planning any involvement by others. Listen to your clients' descriptions of their social worlds. Set goals with which your clients are comfortable and be as specific as possible.
• Be very careful to address issues of confidentiality. Your client should feel in control of what is revealed and under what circumstances.
• Remember, others are being enlisted as your client's allies, not yours. Do not allow others to change the primary partnership that exists between you and your client.

Another source of social support that may complement individual psychotherapy is group work - support groups, self-help groups, and therapy groups. Groups can do many things that individual therapy cannot. They can reduce the feelings of isolation and shame that are so common among survivors, giving them a place to both speak and listen, to discover both their commonalties and uniqueness. Groups also allow survivors to experience themselves as both helping and being helped by the same people, thus creating an atmosphere of mutual empowerment. Groups can also increase a survivor's awareness of personal strengths and resources very effectively. In many groups there is an expectation that people will be more open and direct than is often the case in other social settings. Survivors often receive feedback from other participants which can challenge assumptions and attitudes that have their basis in defensive reactions to past abuse.

Not all of these types of groups function in the same way, however. While these labels are sometimes used differently, in general the types can be distinguished both by their structure and their goals. Therapy groups are led by trained therapists, who assume a different kind of responsibility for monitoring and directing the group process than other participants. Therapists also do not participate in the group interactions in the same way other participants do, therefore, since they should not allow themselves to get so focused on their own issues and reactions that they cannot observe and respond to the whole group's dynamics. This often allows therapy groups to address more difficult, potentially disturbing issues in more safety, since interactions among members are being observed and can be stopped, examined, and redirected when necessary. Therapy groups also are more likely to have an explicit goal of facilitating change, and members expect to be challenged to examine and change their ways of thinking, behaving, and feeling.

Support and self-help groups vary greatly in their structure and can often be defined generally only by the lack of a therapist leader. Support groups may or may not have a designated facilitator, but that person does not usually have the same responsibility for the group's process as a therapist would and may participate more fully as an equal group member. Self-help groups do not usually have a designated leader or facilitator, although group members may take on responsibility for specific group functions. The groups may have consistent participation by the same members, or may have no such expectation of commitment to attend regularly, functioning more as "drop in" groups that members use when they are in need or want. The goals of these groups are often less specific, and may vary greatly among members in any specific group. Often there is more emphasis on support rather than on promoting a specific type of change or growth. Because responsibility for the group's functioning lies squarely with the members, these groups can often be very empowering, but may also be a less protected environment for dealing with issues which feel overwhelming or which make the individual feel very vulnerable.

Therapists should help each client evaluate potential group participation in terms of the individual's needs and goals. Just like relationships with individuals, relationships with groups can be more or less helpful, and can even be destructive or abusive. Thus, the survivor has really two types of questions to consider when thinking about whether to participate in a group. Does the survivor have needs which could be potentially addressed in a group, and if so, what type of group would meet those needs best? And does this particular group, with these particular members, function in a way which works for the survivor? Because a group setting is often very frightening to survivors who are used to hiding their thoughts and feelings, the individual therapist can often be very helpful in both facilitating this connection, and in helping survivors evaluate their participation in a way which validates their experiences but does not reinforce their negative expectations (of themselves or others) which are based on past abuse rather than the actual group behavior.

A special issue which comes up when looking at therapy in relation to other parts of the survivor's life is that of the therapist as an "expert witness" in legal proceedings involving the survivor. Therapists need to be very aware that the structure, goals, and rules that apply in psychotherapy are very different from those that apply in the legal arena. Legal proceedings are based on an adversarial process intended to resolve conflicts either between individuals or between the state and an individual. The goal is most certainly not healing. Therefore if therapists decide to become a witness in a legal proceeding, they need to recognize that their role as a healer, and even the effects that the proceedings may have on the survivor, become irrelevant. Therapists who make this choice must recognize that they have become participants in an adversarial process, and that they will be challenged in ways which may have little or nothing to do with their therapeutic relationship with their clients. The rules that govern what is relevant in a courtroom are very different that those that govern what is relevant in the therapy room.

• Don't go into any legal proceeding unprepared and uninformed. Know what it is you will be expected to be an expert on - your client's psychological functioning, the effects of abuse on behavior in general, some other specific question. You need to seek advice and information.

• Being an expert witness is not the same as being an expert therapist. An expert witness must also understand what it means to give legal testimony, not a topic typically covered in a therapist's training. You can do your clients more harm than good if you think that your knowledge of psychology is enough to make you a good witness. If you are interested in doing legal advocacy as a therapist, get specialized training.
• Exposing the therapy relationship in a courtroom will change the relationship. Sometimes these changes are predictable, sometimes they are not. Often there are at least temporary negative changes, and it may be difficult to restore the sense of safety around the therapy relationship. Discuss this issue clearly with your clients. Make sure that both of you understand that you may be asked tough questions which you will be required to answer, that the questions will be asked in ways which serve the purposes of the two opposing sides, not in ways which necessarily promote a full understanding, and that you will often not be given an opportunity to qualify or explain your answers.

The Therapy Relationship

The relationship between the therapist and the client is really the cornerstone of all good therapy, and the principles of all good therapy also apply to therapy with survivors. However, there are some special issues that may come up in working with survivors which affect the way those principles are applied.

Survivors have often been forced to keep secrets in order to survive, either because they or others on whom they depended were directly threatened with harm if they did not or because they believed that speaking out would lead to harm, rejection, or shame. Over time, they may have difficulty believing themselves, since there is little or no external validation for their perceptions or memory. For this reason, their attempts to speak about their experiences are often extremely difficult and they will monitor the reactions of their therapists carefully for signs that they are not believed.

A therapist who works with survivors must be prepared to listen carefully and with respect to their accounts of their experiences. However, believing that clients are telling the truth about their experiences is not the same as accepting their perspective as complete or their interpretations of events as objective reality. We do our clients no service by accepting uncritically everything they say, since we would often end up reinforcing the distortions they have developed to protect themselves from overwhelming pain or fear. For instance, survivors often believe that they are somehow responsible for abuse they receive at the hands of trusted others such as parents. Survivors may believe that parents were abusive because they were trying to correct bad behavior; that the abuse was actually an indication of parental love. Believing this may have protected them from having to face the fact that they were dependent on adults who were actually dangerous.

Therapists must help survivors speak of all the pieces of their experience and find their truth in the total picture that emerges. Some of that picture may continue to contain uncertainty, since there will always be some things which cannot be known or understood completely. Survivors need to learn to trust themselves to know and speak their own truth, not to trust us to tell them the truth of things of which we have no direct knowledge. If we recognize that there are inconsistencies in their interpretations, or if other possible interpretations have been ignored, we help them find their truth by pointing this out.

This is true for obvious distortions such as believing abuse is an indication of love; it is also true for assuming the only alternative is that abuse indicates hate. At the same time, every interpretation and assumption survivors make tell us something about the reality of their lives and experience (e.g., why would a child need to deny any anger with an abusive parent?). We help our clients to listen to themselves by listening carefully and respectfully to everything they say and not rushing too quickly to certainty about an objective truth.

Working with survivors, especially those who have experienced victimization in childhood and/or repeated victimization, may require an investment of time and energy which is somewhat different from that required by other clients. If we encourage survivors to face the full psychological and emotional reality of their victimization, we are also de-stabilizing the systems they have developed to manage their emotions. They need to know we are there to help them through the transition period until new systems have been developed. Especially during crisis times, this may mean having more flexibility about meeting times, phone contacts, etc. There may be an extended time in which we are the only ones with whom survivors feel safe to speak the truth, and therefore we will be a critical source of validation when they feel doubt and fear.

We also need to recognize that we cannot assume responsibility for single-handedly changing survivors' negative experiences. We cannot be available at all times, always able to meet their needs. The clearer we can be with our clients about what we can and cannot do, the less likely we are to leave them feeling like we have betrayed the trust we promised. However, it is also important that we make it clear that their needs are legitimate, even if we are not able to meet them all, since survivors have often been given the message that their needs are unreasonable (or even that any needs are unreasonable). Finding the balance between the flexibility they require and recognizing our own limits can be difficult but is important. We should discuss this issue openly, and as often as needed, with our clients. Also, consultation with supervisors and colleagues who have experience working with trauma and abuse is very important in maintaining this balance.

Within many traditional approaches to psychotherapy, therapists are encouraged to maintain a "neutral," emotionally uninvolved stance in relation to clients. "Services" are provided in ways that are regulated by the therapist alone, and attempts to change these rules by clients are often interpreted as "manipulative." (The diagnosis of borderline personality disorder is often both the source of and justification for these interpretations.) However, this approach to therapy can have negative consequences for survivors, for whom lack of control has been associated with injury and violation. Survivors need to know that they have influence in the therapy setting and that they have an effect on the therapist as a human being in order to feel safe and begin to develop trust. This does not mean that they need to be in complete control, only that they need to know their feelings and needs are being taken into account. Therapists need to be comfortable sharing control in working with survivors.

Showing emotions in the context of human reactions to the survivor's experience can also be an important source of validation for the survivor, and a highly effective way of modeling healthy ways of expressing emotions. When working with survivors, therapists who feel a strong need to control all emotional expression may end up putting more energy into protecting themselves than into attending to their clients, since much of this work is emotionally difficult. Because their trust has been so violated by others on whom they felt dependent in the past, survivors often assume the worst in their interactions in the present. For this reason, they may need more feedback about what their therapists are thinking and feeling than would be true for other clients. This feedback can also be an effective way to begin challenging distorted perceptions and beliefs.

Survivors may also be labeled "manipulative" if they attempt to control the therapy in indirect, covert ways. It is important that therapists recognize that this indirectness has often been developed as the only safe way to influence their social environment. If clients have "hidden agendas" in their interaction patterns, it may be because staying hidden was essential in their efforts to survive; to meet the needs that could not be addressed safely in more open ways.

When therapists interpret clients' behavior as attempts to control the therapists rather than as the clients' attempts to meet their needs the only way they know how, the therapists are more likely to react defensively and to set up a struggle for power in the therapy. If the therapist feels that this covert process is occurring, it is much more effective to redirect the interaction by helping the client identify the needs that are being addressed this way, and then deal with these needs more openly and directly. This not only reinforces the sense of mutual respect and control, undermining any struggles over power, it also models new ways of interacting and exerting power that the client can use outside the therapy setting.

The realities of social services in this country provide other challenges to a therapist's work with survivors. Many therapists work in settings which do not give them many options in the work they do with clients, severely limiting the frequency and timing of sessions, the access clients have to their therapists between sessions, the kinds of therapy that can be provided, and so on. Therapists who have to work within these restrictive conditions can help clients identify and validate all their needs, can support their efforts to meet some of those needs in other settings, and can advocate for clients within the therapists' agencies and with funding sources. In these circumstances, coordination of services with victim services providers can be especially important.

Though limited, the psychological services therapists can provide in these situations can be useful in and of themselves, and may help empower survivors to take their experiences and needs seriously and seek out additional help. However, recognition of the inadequacy of these services can be very difficult for therapists, who may be left feeling disempowered and discouraged. Just as for our clients, it is important for us to seek out support for our work, validation for our perceptions, and the empowerment that activism in the community can give us.

This topic is usually addressed in terms of transference and countertransference. However, these words have been used in very imprecise ways in the professional literature. Originating in psychoanalytic theory, transference referred to the client's tendency to react to the therapist in ways that unconsciously identify the therapist with significant others in the client's life. Countertransference is the same process, but involving the therapist's reactions to the client. The words are currently used much more generally by those who do not necessarily have a psychodynamic orientation to refer to the way both client's and therapist's personal histories affect their perceptions of and reactions to each other.

Because the work with survivors is often emotionally intense and requires so much openness to emotional experience on the part of both client and therapist, it makes sense that both are likely to feel quite vulnerable. For survivors this means that defensive strategies that protected the survivor in the past are going to be used in the therapy and with the therapist. Clients try to fit their therapists into the conceptual and emotional frameworks they have developed over the years, giving their therapists roles that are based on the survivors' abusive histories. Some of these roles can be quite flattering to the therapists, and can provide a great deal of emotional gratification.

Therapists can be seen as rescuers, strong and decisive. They can be seen as perfect, nurturing parents; as kind and tolerant lovers; as powerful authority figures; as brilliant, intuitive seers. It is critical, for the sake of both the client and the therapist, that the therapist recognize these perceptions as expressions of the survivor's unmet needs, and not confuse these perceptions with their self-identification. Accepting these perceptions in self-gratifying ways is ultimately harmful to the clients, at best leaving distortions unchallenged and at worse setting them up for yet another betrayal by someone on whom they had a right to depend. However, telling survivors that they are "wrong" and that their perceptions are invalid (only transference) only encourages them to hide these perceptions and rarely changes them, pushing them underground in the therapy interactions. Helping clients use these perceptions and wishes to understand their past experiences is another way of recognizing the ongoing effects of earlier victimization, of validating their experience without reinforcing the problematic adaptations they have had to make.

Sometimes the roles that clients impose on therapists are not so flattering. Many survivors have learned to protect themselves by staying on the alert for injury or betrayal. They may feel less vulnerable seeing the therapist as an uninvolved "professional helper" for whom the survivors are just another job. They may see therapists as weak and ineffective when they cannot make everything better quickly for their clients; as rejecting and uncaring when they set limits or are not immediately available; as critical and punitive when they give any "negative" feedback; as sexually seductive when they express caring or concern.

Perhaps the most distressing role for therapists who have worked hard to establish trust and safety with their clients is to be seen as abusive, to be identified with the survivors' abusers in any way. It is very difficult for therapists not to respond to these perceptions defensively, feeling hurt and angry, arguing their innocence. As with the more "positive" distortions, therapists must be able to see these confusions for what they are, and help clients recognize how victimization has become incorporated into their understanding of themselves and others.

It is important to note that awareness of transference processes should not be used to deflect and explain away all negative feedback we get from clients. If clients have complaints, we need to listen carefully and respectfully. We do make mistakes, and when we do we need to acknowledge them and apologize. This is not only ethical behavior on our parts as therapists, it is also an important way of helping our clients learn how to trust their ability to recognize injury in the present. Often when clients have complaints about us or our behavior, there is both a real problem in the present and a transferential interpretation of that. We need to help our clients sort these out and find effective solutions.

Just as clients have experiences and needs which affect the way they react to the therapist and the interactions in therapy, therapists bring their experience to their interactions with clients. Therapists need to be constantly aware of the potential for our own experience to affect our interpretations and emotional reactions. Do frustration and "setbacks" in therapy trigger feelings of hopelessness or doubts about our competence, leading us to seek reassurance from our clients that things are going well in therapy? Are we so uncomfortable with being seen in sexual ways by our clients that we cannot address our clients' sexual feelings or thoughts? Are we afraid of being taken advantage of, and therefore react defensively to our clients' expressions of neediness or disappointment? Do we need our clients to like us so much that we discourage expressions of anger with us or avoid confrontations when they are needed? These are just some of the ways that our own issues can be brought into our work, interfering with therapy. A relationship with a supervisor and/or colleagues whom we trust with personal information is important in examining these reactions in an ongoing way.

Working with survivors can have special significance for therapists who are also survivors. They may identify strongly with their clients, and care deeply about their clients' healing and recovery. This common experience can be helpful in many ways for both therapist and client. It can facilitate both understanding and empathy on the part of therapists.

If the therapists have experienced their own healing, it can powerfully reinforce feelings of hopefulness which are communicated to clients both directly and indirectly, and which can support the therapists through the difficult periods in therapy. However, it is really important that therapists be able to distinguish their own experiences and those of their clients. If a therapist's identification with the client means the therapist's own sense of safety can be undermined by the client's victimization or difficulty making changes in abusive relationships, then a therapist is likely to feel anxious and insecure and communicate this doubt and fear to the client. If a therapist's own anger at her/his abuser is allowed to be directed at the client's abuser, the client's anger may remain hidden or get distorted, or the client may fall back on a defensive protectiveness of the abuser.

It can also be distressing for a therapist, who is also a survivor, to be perceived as abusive by a client that the client's transference cannot be addressed. Therapists who are survivors need to know their own limits in terms of how much stimulation of their own pain and fear they can tolerate without becoming defensive in ways which make therapy impossible. They need to be willing to balance their desire to help other survivors with respect for their own needs.

Social roles, the culturally defined sets of behaviors associated with particular positions in society, affect the way all of us interact with one another. We often use these social definitions to guide our own behavior and expectations of others without conscious awareness we are doing so. We may sometimes actively reject aspects of these definitions, expanding our perceptions of others beyond the restrictions of their assigned roles. Usually we are doing both. Whichever attitude we assume at a particular time, we cannot escape the influence of our culture since we must deal with it whether we resist or accept its prescriptions for ourselves and others.

The ever present reality of social roles is an important consideration in all therapy, since the basis of therapy is the interaction between two individuals who exist within particular cultural contexts. Usually discussions of this issue encourage therapists to be aware of the cultural and social position of clients, and how these factors affect the clients' behavior, thinking, and emotional reactions. While this is certainly important, it is just as important for therapists to be aware of their own social and cultural context, and the way these affect their behavior, thinking, and emotional reactions.

Often those who participate in the status and privilege of culturally dominant positions (who are white, middle or upper class, male, or heterosexual) are unaware of the extent to which their own roles are just as culturally determined as those of groups who stand out as different from the culturally dominant norms.

Both "normal" and "different" are culturally determined and both need to be examined by anyone who wants a comprehensive understanding of another person's experience. It is important to remember that even identification with a particular group is at least in part a question of social assumptions and norms (for example, an individual whose genetic heritage is one-tenth African and nine-tenths European would still be identified as African American by most people in our society; another person who is one-tenth Irish and nine-tenths German would be unlikely to be defined as Irish American). Also, social roles are usually talked about in terms of group differences; they actually define similarities as well.

In the arena of social roles we are rarely if ever dealing with "different but equal." Social groups are arranged in complex patterns of relative social status. Status is an expression of a particular socially defined group's perceived social value and power in relation to other socially defined groups. Social value and power are expressed in a wide variety of ways: the group's share in the distribution of limited resources; the incorporation of a group's interests into social policy; the visibility of a group's perspective in the media and the arts; and so on.

The behavior of individuals is often judged in relation to the status of the group with which they are identified. For example, becoming a medical doctor will have different significance to others if the individual is female or African American rather than a white male; it may be perceived as an exceptional accomplishment, as a threat, as an aberration. Similarly, becoming an auto mechanic would be seen differently if the person is the son of an upper class white family rather than of a working class family; it may be perceived as a shame, as an act of rebellion, as a failure. Power, the ability to influence and direct the social environment in which we live, often derives from the shared power of the groups with which we are identified. Without the collective power of the group's recognized authority and influence, we become isolated and vulnerable.

These forces clearly affect the therapy process as well, as both therapists and clients view each other through the social lenses of roles and status. While this social context cannot be escaped, it can be made visible, and challenged when necessary. Awareness of the way social position has shaped the experiences of both the therapist and the client is important if both are going to fully understand the client's experience. Unrecognized differences between therapist and client in the way events are interpreted can lead to misunderstanding and the inability to build a working relationship.

For survivors in therapy this can mean the reinforcement of emotional isolation, shame, and negative images of the self. It can be experienced as a re-enactment of the invisibility and silence that have been so destructive in the past. When therapists are unaware of or deny the effects of their own social power and privilege relative to their clients, the therapists actually make it difficult to cooperatively construct a therapy environment in which clients can experience their own power and value. At worst this lack of awareness can lead to an abuse of power (either intentional or not) which further victimizes survivors and confirms rather than changes their experiences and beliefs.

There are many different types of social roles which are relevant to therapeutic work with survivors (as well as with other clients). Gender roles are clearly of central importance, since these have such significant implications for both personal experience and for social power. Gender roles are particularly important in the dynamics of domestic violence (including all kinds of abuse which occur in the context of personal relationships) since gender is an organizing concept in the structure of the family and intimate relationships of all types. Thus, the experience of victimization will be different for men and women, and will also be affected by the gender of the perpetrator. Male against female abuse is so common and familiar, and so supported by social norms which make "normal femininity" almost equivalent to the role of a victim, that the victimization of women becomes invisible and hard to recognize.

Cultural and ethnic differences also affect the way abuse is experienced, and therefore the effects it will have on the individual. There is great variation in the norms governing what behavior is socially acceptable, how violations of acceptable behavior should be handled within the group, and when and how such violations should be revealed to "outsiders." Abuse will also be experienced very differently when it occurs within a group (when the survivor sees the perpetrator as a member of the same cultural community) and when the perpetrator is perceived as an "outsider." When group ties form the basis for a strong identification with the perpetrator, the confusion, sense of betrayal, and difficulty with anger and assigning responsibility can be reinforced (as when abuse occurs within a family). When the abuse occurs across socially defined groups differing in status and power, these social differences can increase the sense of threat, powerlessness, and inadequacy that are created by the victimization. Therapists need to be aware of these larger social issues and help their clients become aware of them as well if the survivors are to become effectively empowered to identify and challenge all aspects of the abuse.

• Start with yourself; increase your own awareness of how your background and social position affect your thinking and behavior. Do not make the mistake of thinking only your clients' lives require examination, and use every confusion and miscommunication that occurs in therapy to increase your awareness of the unconscious assumptions you carry. This will make it easier for you to recognize the influence of culture on your clients, and not mislabel these differences between you as evidence of pathology.
• It is your responsibility to be informed about social differences. If you are going to be working with someone who comes from a different social background, learn all you can about the experiences you do not share. If there is a social gap between you, it will require both of you to work to build a bridge; don't make your client do all the work. Remember, survivors have already had to do too much adapting to a social world in which their experiences are invisible or discounted.
• Understand that social structure is complicated and that each individual has connections to many groups. Inner-city Jewish experience is not the same as suburban Jewish experience, but individuals from both settings will have things in common not shared by their inner-city and suburban neighbors from other ethnic groups. Class, gender, geographical location, education - these and other factors will affect experience within a cultural group, just as cultural background will affect the meaning of gender, class, and so on.
• Remember you cannot completely rise above or eliminate the effects of social status and power in the therapy relationship. For instance, a male therapist cannot erase his social status and power, and the meaning this would have for a female client, no matter how much he would like to have equality. By acknowledging this social reality, however, he can validate the client's perceptions and create a climate in which the client can be empowered to challenge these social roles. In this environment, they can together find mutual respect and power based on their ability to create common ground.
• Know your limits when dealing with social differences between yourself and your client. Especially for clients who are survivors, differences between you such as gender can be powerful triggers for emotions associated with abuse. If these reactions are too strong and cannot be balanced out early in therapy by other factors which foster a sense of safety, they can overwhelm the best efforts to establish a working relationship. This is when a referral to a different therapist is appropriate. It does not mean that you have failed as a therapist, only that you cannot be all things to all people.

Some clients with whom we work are particularly vulnerable at least in part because of their identification with social groups which have little or no status and power within this society. Awareness of these areas of vulnerability is important in working with survivors who have already been injured by abuse of power.

• Previous history of involvement with the mental health system. Individuals who have been labeled as mentally ill often have difficulty being heard and believed when reporting abuse or victimization. Once their credibility has been questioned, their descriptions of their experience are often explained as symptoms of their illness. Also, these individuals are often perceived as socially marginal and without powerful advocates or defenders, and therefore may be seen by perpetrators as safe targets for victimization. Thus, current or previous mental health problems may increase a person's chances of being abused and reduce their ability to deal effectively with abuse when it has occurred. While the cognitive and emotional disturbances that characterize mental illness certainly distort perceptions and experience (for instance, in psychotic conditions), we cannot automatically assume that accounts of abuse are unfounded. It is our responsibility to listen carefully to our clients, perhaps even more so when their ability to comprehend their environment is compromised in some way.
• Substance abuse and dependence. Many of the same concerns apply to individuals who are struggling or have struggled with addiction. Their credibility is often in question, and they are also often marginalized. For these reasons they may be easy targets for abuse and less able to defend themselves. In addition, social attitudes toward substance abuse are still quite punitive, and these survivors are often seen as responsible for abuse that occurs when they are intoxicated. They are often perceived as undeserving of sympathy, or less seriously affected by abuse than more "innocent" victims. Conversely, perpetrators (particularly male) often are "excused" for their behavior because they were "under the influence."
• Dependence on others for protection. Those groups of people who are dependent on others for basic physical and social needs are also more vulnerable to victimization and less able to seek help on their own. These vulnerable groups include both the young and the old, for whom social stereotypes also involve diminished credibility. Financial dependence often restricts the ability to stop abuse by those on whom the survivor is dependent (as in much domestic violence). It also restricts a survivor's access to basics needed for healing: safety (such as a safe place to live), legal protection, medical services, and certainly mental health services. Others who are vulnerable at least in part because of their dependence on others are those with physical and mental conditions which limit their ability to function independently. When the social and physical environment presents obstacles to even day to day living for these individuals, victimization and abuse can be overwhelming.
• Socially powerless and stigmatized groups. In order to address issues of victimization, someone else has to be willing to listen and care. There is little of this interest and caring on the part of those with power for some groups of people; abuse and hardship may be seen as normal and even acceptable for these less powerful groups. This is especially true for the poor and near poor. Also, in order for someone to speak out about abuse, it has to be safe to be seen and heard. For stigmatized groups this is often not the case. Their safety in this society may depend on being invisible, and seeking help may involve being identified and further victimized by those who should be providing help. This is often the reality of day to day life for lesbians and gay men, for whom harassment and abuse are often socially tolerated or even encouraged.

Often vulnerability to abuse is confused with responsibility for abuse. It is important as therapists to be clear that it is not the nature of the victim that defines abuse, but the nature of the perpetrator's behavior. We do not determine whether a behavior is abusive based on how hard or easy it was for the perpetrator to commit. Being less protected, or less able to defend oneself, is not the same as inviting abuse. This is a distinction that is important to help survivors make.

Sometimes therapists have difficulty addressing issues of vulnerability with their clients because the therapists do not want to imply any victim blaming. While vulnerability is never a cause of abuse, vulnerability to abuse is still a serious issue and needs to be addressed. Feeling better able to protect themselves is an important goal for most survivors, and recognizing areas of vulnerability is one step toward that goal.

In some cases there is little that survivors can do to eliminate a particular area of vulnerability. In this case, empowerment can mean developing the resources the survivors do have, finding other sources of strength both within themselves and within their communities. Acknowledging limitations and vulnerabilities should not be the same as helplessness or resignation to continuing victimization.

In other cases there are things survivors can do to reduce their vulnerability to abuse. Survivors can become more aware of their right to say no. They can address problems related to alcohol abuse. They can leave abusive relationships. These personal changes are often difficult, in part because past abuse reduces survivors' self-confidence. However, making a commitment to change can be an important way for survivors to reclaim their power, and limit the continuing effects of the abuse.

Many of the factors which affect the work we do as therapists operate within a much broader framework than the therapy relationship, or even the sum total of the relationships in our clients' lives. Social and economic forces shape what resources are available, who will have access to these resources, and under what conditions. Currently there is little consensus in our society about the appropriate social response to the needs of survivors, and even about the nature and extent of the problem of victimization. Much progress has been made increasing awareness of the extent of violence and abuse and of the consequences of abuse for both the individual victim and the society as a whole. However, a predictable but still frightening backlash has developed in response to this progress.

In its broadest form, the voices of the backlash object to the focus on victimization. They argue that identifying the frequency of abuse and addressing its long term effects encourage the development of a nation of "victims" who are paralyzed by self-pity and ready to blame others for their current difficulties. To the extent that the problems of abuse and violence are addressed at all within the backlash, they are seen as relatively minor, abnormal events or as the behavior of an isolated criminal element rather than as a part of the fabric of American life. Victims are encouraged to "leave the past behind them" and not expect any "special treatment" because of the abuse. Often the focus is shifted away from the survivors' experiences and on to the effects on other people when survivors speak out. For example, the disruption of family ties becomes more significant than the abuse that occurred within that family, or the price the survivor has to pay to maintain those ties.

The message of the backlash has a powerful effect on both survivors and the therapists who work with them. It leaves survivors doubting their emotions and perceptions, sometimes even the reality of their experiences. The backlash defines survivors as the problem, reinforcing the messages of their victimization. It fosters a minimizing of the effects of abuse, making it difficult for survivors to effectively address them. And it encourages survivors to automatically put their own needs second to those of others, including the needs of others to be shielded from the truth.

The voices of the backlash have become powerful and organized, often making survivors feel even more unsafe and afraid to speak out or seek help. Survivors are afraid they will not be believed, that they will be perceived as bad. These powerful voices also lead survivors to be afraid of the very people who offer help. Therapists and others who provide services to victims and survivors are publicly blamed for creating the problem, rather than simply exposing it. The messenger is attacked because the message is unacceptable.

The effects of the backlash are seen clearly in the "memory debate," in which the validity of survivors' memories of abuse is questioned, especially if the memories emerge after a period of being unaware. (See "Honoring the Truth: A Response to the Backlash" in Bass & Davis, The Courage to Heal, 3rd ed., for an excellent review of this issue.) Survivors are accused of manufacturing these memories for attention or other secondary gains, and their therapists are accused of encouraging this to keep clients dependent and to increase their profits. (It is interesting that the validity of the memory of those accused of abuse is not subject to the same scrutiny even though they clearly have a much more obvious self-serving motive for distorting their memories of events.)

The debate has often oversimplified the understanding we do have of memory and the way it works, especially in cases of trauma. (This oversimplification is apparent in the frequently quoted work of Elizabeth Loftus, and is critiqued by those who have the most extensive understanding of the effects of trauma on memory, such as Judith Herman, John Briere, Christine Courtois, Bessel Van Der Kolk and David Calof). Therapists must have an understanding of these issues if they are going to work with survivors, because survivors' experiences and memories are often fragmented and confused. There have been therapists who have interpreted their clients' symptoms and feelings as proof of abuse, substituting the therapists' beliefs and expectations for the clients' experience. To recognize that a client's feelings and behavior are consistent with a history of abuse (and to explore these reactions with the client) is an appropriate use of our professional knowledge. To pronounce that we as therapists know what happened, especially when our clients do not, is inappropriate.

Therapists are often the target of the backlash's anger and fear. Groups such as the False Memory Syndrome Foundation actively support family members accused of abuse in lawsuits against survivors' therapists. They publicly target therapists who specialize in work with trauma-related issues, and have developed an extensive media campaign to promote their views. In this climate it is easy for therapists to feel vulnerable and under attack, and to react defensively. We can feel afraid to trust our clinical judgment, or to intervene in ways that we know would be helpful to our clients. Or we may become so angry that we reduce the whole issue to a black and white, us versus them siege. The best protection against either of these defensive reactions is a strong connection to other service providers who are committed to self-examination and professional growth but are also willing to challenge the attacks from the backlash directly and publicly.

Although the number and types of services available to survivors has increased dramatically since these issues began to get more public attention, resources are still very far from adequate. As economic pressures have increased in society as a whole, and the social climate has changed, the resources that have been available have decreased or come under attack. The general economic decline also leads to decreases in the numbers of survivors who are able to afford services. Unfortunately, mental health services in general, and services for survivors in particular, are often seen as social "luxury items" which can be cut out without too much effect when money gets tight. In this climate, the services themselves become undervalued, and the providers are seen as less deserving of compensation. Therapists and service providers are caught in the middle, feeling overwhelmed by the needs they are trying to meet and receiving less and less in the way of financial and social support.

Unfortunately, providers who meet different but equally important needs of survivors are often in competition with each other for limited economic resources. This can lead an agency or group of providers to see others as threats to both its ability to provide services and to its ability to sustain itself and its employees. When agencies or groups become self-protective in this way and begin to protect their turf, services become fragmented and survivors suffer as well as providers. When resources are limited it becomes even more important to develop cooperative relationships among different providers. This allows for more efficiency in providing services, and less waste of resources, effectively strengthening each member. Gaps in services can also be more easily identified and addressed. Cooperation allows providers to present a stronger, more united challenge to those who question the value of this work, or who would like to maintain their denial of the need for it.

Caring for Ourselves and Each Other

Psychotherapy with survivors of abuse and trauma is difficult work, for both the therapist and the client. Not only is the work of therapy draining, but the constant exposure to the pain and fear that result from trauma can be traumatizing itself. Therapists need to know that the energy, motivation, creativity, caring, even hopefulness they need are not self-sustaining. We must be nurtured in our lives outside the office, because our clients cannot and should not be expected to keep us going. Therapists' perceptions, beliefs, and interactions become cynical and distorted, or just drained of emotional vitality, when their lives become dominated by the reality of violence and abuse of power. The experience of pain needs to be balanced by the equally powerful realities of joy, intimacy, love, fun, hope, accomplishment.

It is easy for therapists who are committed to their work to become overwhelmed by the immense need they see. The reactions we have to our inability to meet all those needs vary among therapists, and from one time to another for each therapist. We feel frustration, self-doubt, helplessness, fear that the whole world is being overwhelmed with violence and pain. We may find ourselves shutting down emotionally to protect ourselves from these painful feelings, and thus become detached both from our clients and from our families and friends. We may find ourselves having difficulty responding fully to the real hurts and needs of family, friends, and ourselves when they seem so "minor" compared to the horror of our clients' lives. We may feel angry with clients for frustrating our need to feel effective, competent, in control - our need to feel we can change things. We may try to resolve our own histories of trauma through our clients, and thus not experience our own healing. We may become overwhelmed by despair when our best efforts cannot stem the tide of violence and abuse.

These reactions can be countered most effectively in the context of strong connections to our communities. Professional communities can provide a sense of shared experience, as well as an understanding of our frustrations and accomplishments. With others we can feel visible ourselves, and the realities of our clients' lives can also be visible and taken seriously. We are less likely to feel that change depends on us as individuals. And we can also work for change at the societal level, feeling less restricted to our individual worlds. These communities can provide a powerful antidote to the poisonous message of abuse - the message that no one hears you or sees you, no one cares. However, we may need to look for these communities and put some energy into staying connected to them. Unfortunately professional groups are as susceptible to the denial of painful truths as society as a whole. Groups which consist of coalitions across disciplines may be more likely to overcome the nearsightedness and restricted experiences which hamper some professional groups.

Relationships with supervisors or consultation groups can be a good way of addressing the links between our personal histories and our professional work. These relationships require trust and mutual respect in order to feel safe and supportive rather than shaming and judgmental. The reality of work within many organizations and agencies is that good supervision and other support for staff is either undervalued or unavailable. We may need to seek it outside the work setting.

Our personal communities of family and friends are also critical. Within these we feel valued and valuable. We can experience the hopefulness of growth. We can reconnect with the reasons why healing is important and worth the effort. We need to treat our personal lives as valuable and worthy of protection, not just as something we do when we're not working. Our personal lives should not always be expected to step aside for our work (for meetings, phone calls, appointments, and so on). This requires a balancing act, since our work and our personal lives are not often nicely coordinated. Colleagues who are also friends can help us with frequent reevaluations of this balance. It isn't just enough to have family and friends; we have to live fully among them.

• Remember you're not alone. You are part of an important process that extends over time, and encompasses many people. What you do is important because it is part of this process. You can't do it alone, so don't expect yourself to try. But don't undervalue the contribution you do make. Without you the process of change would be weaker and slower.

Bass, E. and Davis, L., The Courage to Heal: A Guide for Women Survivors of Child Sexual Abuse (3rd edition), Harper & Row, 1994.

Blumenfeld, W. J. (Ed.), Homophobia: How We All Pay the Price, Beacon Press, 1992.

Bolton, F., Morris, L., and MacEachron, A., Males at Risk: The Other Side of Child Sexual Abuse, Sage Publications, 1989.

Briere, J., Therapy for Adults Molested as Children: Beyond Survival, Springer, 1989.

Briere, J., Child Abuse Trauma: Theory and Treatment of the Lasting Effects, Sage, 1992.

Brown, L. S. and Ballou, M. (Eds.), Personality and Psychopathology: Feminist Reappraisals, Guilford, 1992.

Calof, D., "Facing the truth about false memory," The Family Therapy Networker, 17(5), September/October, 1993.

Courtois, C., Healing the Incest Wound: Adult Survivors in Therapy, W. W. Norton, 1988.

Chrisler, J. C. and Howard, D. (Eds.), New Directions in Feminist Psychology, Springer, 1992.

Herman, J. L., Trauma and Recovery, Basic Books, 1992.

Herman, Judith L. and Harvey M R., "The false memory debate: Social science or Social Backlash?," The Harvard Mental Health Letter, 9(10), April, 1993.

Lew, M., Victims No Longer: Men Recovering from Incest, Harper & Row, 1988.

Lobel, K., Naming the Violence: Speaking Out About Lesbian Battering, The Seal Press, 1986.

Mirkin, M. P. (Ed.), Women In Context: Toward a Feminist Reconstruction of Psychotherapy, Guilford Press, 1994.

Pearlman, L. A. and Saakvitne, K. W., Trauma and the Therapist: Countertransference and Vicarious Traumatization in Psychotherapy with Incest Survivors, W. W. Norton, 1995.

written for this manual by Mary Margaret Hart, Licensed Psychologist