Rebuilding Shattered Lives by James A. Chu

Author:James A. Chu
Language: eng
Format: epub
ISBN: 9781118015063
Publisher: Wiley
Published: 2011-02-14T05:00:00+00:00

CLINICAL WORK WITH “IMPOSSIBLE PATIENTS”

The general principles of clinical practice used to treat patients with complex posttraumatic and dissociative disorders are described elsewhere in this volume; they are critically important in treating chronically disempowered patients. Some other particularly relevant elements of treatment are also essential in treating these most vulnerable patients.

Clarification of the Therapeutic Agenda

In the treatment of chronically disempowered survivors of childhood abuse, therapists’ understanding of the nature of therapy may differ considerably from patients’ assumptions about therapy. For example, therapists may place a high value on patients gaining a sense of mastery over their lives through better self-care, achieving control over their feelings and impulses, and learning from their experiences. In contrast, chronically disempowered patients may not be able to even conceive of developing a sense of mastery over their lives. Patients may assume that the therapy will simply help them to feel better and that their therapists should do whatever is necessary to care for them and to deal with their feelings and impulses. Given patients’ assumptions about themselves as chronically victimized and powerless, it is not surprising that they assume that there must be some external locus of control in their lives.

Differences in assumptions about the agenda of therapy are remarkably commonplace in the treatment of disempowered patients. Even experienced therapists repeatedly make the mistake of implicitly assuming that treatment goals are shared. When there is not a mutually agreed-upon agenda for the therapy, impasses inevitably arise, particularly around issues such as being taken care of versus learning self-care, and impulsive tension-release versus learning to cope with dysphoric affect. It is the therapist’s responsibility to provide explicit explanation and teaching to patients about the process of therapy. Furthermore, given the chronic disempowerment that patients experience, therapists must provide such psychoeducation at the beginning of the treatment and then again throughout the course of the treatment. The following clinical example illustrates some common issues concerning the treatment process:

Judy, a 32-year-old married woman, had a long history of depression and had been treated for years with psychotherapy and medication. She was on disability and had few demands on her life, but she reported feeling overwhelmed by her family responsibilities. She began a new therapy, and it soon became clear to the therapist that she had problems related to many experiences of childhood abuse that had included intense devaluation and physical abuse. Both outside the office (as described by the patient) and within the therapy sessions, Judy would seem to reenact being victimized. She would bitterly describe how she knew that others (including the therapist) thought of her as worthless, how helpless she was to change her life, and how suicidal she felt. She was convinced that it was her fate to be abandoned (despite a 12-year marriage) and felt that she was of no importance to anyone else.

The therapist would gently try to comfort Judy, empathizing with her despair, but also expressing his conviction that she was worthwhile. He would also remind her of her many accomplishments and her value to her family, helping her gain a better sense of perspective.

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