The more the therapist practices from some theory of "blank screen," neutrality, silence, or distance, the more the PTSD patient will feel anxious pressure to find "the real person" in the therapist to feel safe and the more the therapist will be setting limits and demarcating boundaries. Although it may seem like a question of semantics, the distinction between stating limits and setting limits gets to the heart of the way authenticity, real engagement, and mutuality operate in relational-cultural therapy. Rather than setting limits, which involves use of power over the other and often carries connotations of the pathological and overwhelming nature of the patient's needs, it is important for the therapist (and patient) to state their limits. This involves making use of the therapist's authentic responsiveness and inviting the patient into a relationship where there is respect for difference, tolerance, and learning about how each person affects the other. Both therapist and patient hold some accountability and responsibility for their impact on the other and on the relationship. For instance, as to the question of phone calls, therapists speak of setting limits on the number of phone calls that a patient can make to the therapist between sessions. often, there is the implication that there is a big black hole, an endless void, a bottomless pit of need, and an insatiable desire for contact that is "sick," impossible, and frustrating. Therapists often feel angry about the patient's "excessive" need for contact between sessions. This is not to suggest that the anger is wrong but that the frustration of this situation, rather than being treated as occurring because of the patient's insatiability, is seen as a dilemma for the relationship. The need for contact can be honored at the same time that the realistic limit on such frequent contact can be managed by patient and therapist. For instance, the therapist really cannot attend to five phone calls a day from a patient; but the patient genuinely feels the need for the contact and reassurance at certain times in the therapy. it is important that the therapist state his or her limits: "I realize you really need to talk with me frequently during the day to feel connected and safe, but I simply cannot physically do it. I wish i had a clone or i had that kind of time, but since i don't, we have to figure out together how to make sure you get what you need and i don't feel so pressured or bad about not being able to be there for you. Together we have to be responsible for making this relationship work for both of us." This is not offered as a technique but as an example of how authentic responsiveness may make more sense than attempting to control or set limits. It is important that people get to know the impact of their actions on others. Patients inevitably must learn to grapple with the frustrations of not always being able to get exactly what they want; but it is essential that people have their needs and desires respected. People must also learn to negotiate conflict in a way that is respectful. In these encounters, patients learn that they can say no, while still caring about the impact of that no on the other person. They also discover in the process that the connection can endure.
The neutral, objective, authoritative stance of a traditional therapist feels dangerous and hurtful to the abuse survivor. This withholding stance can trigger panic and traumatic disconnection. Although all relationships initially feel terrifying for the PTSD patient, where there is authenticity and responsiveness, trust will slowly but, not necessarily, steadily grow. In RCT, both members of the therapeutic dyad will learn ways to trust each other; this is a mutual journey. It is natural that anger will be a part of this relationship; carefully modulated and thoughtful sharing of the therapist's anger or frustration will be of use to patients as they struggle to find a voice for their own anger and protest. The "borderline rage" that many talk about is best understood as the pent-up protest about awful relational injury that the child was unable to protect himself or herself from. In tolerating the intensity of this communication and experiencing it as a mere echo of the earlier pain, a deeper appreciation for the patient's suffering develops and leads to enhanced empathic connection. If the therapist can better grasp the terror and helplessness of the child victim, perhaps the therapist will find ways to be with that terrified anger, respect it, and help the patient find useful ways to express it. Therapists must honor both the desire for connection and the strategies of disconnection.
Similarly, the therapist must grasp the depth of shame and isolation that many people with PTSD struggle with. Shame seeks isolation and dwells in silence. It interferes with movement back into relationship. Our shamed parts are the last we want anyone to see or know. In shame, there is no hope for empathic possibility; we feel no one could possibly resonate with us. We are alone in shame. We lack self-empathy and compassion as we blame ourselves for what was done to us. We are disconnected from others and from ourselves.
In working with all of these challenges, therapists need to learn about relationships, relational failures, chronic disconnections, relational images, reestablishing empathic possibility, and relational resilience. We need to find ways to help people move from disconnection to connection. Therein lies hope. To help build connection and create the possibility for reconnection, we must work from a place of deep respect for our patients, with humility about our own efforts and openness to being moved and affected, which creates a nonjudgmental, nondefensive, and empathic presence.
Some of the personality diagnoses seem subtly disrespectful, some explicitly so. There is always the danger of the we-they dichotomy in treatment of patients. Objectification or assuming a position of "better than" is profoundly nonrelational and does not contribute to healing. In fact, it may push the patient into deeper isolation and despair. Often, therapists participate unwittingly in the illusion of having transcended difficulty in their own lives ("Oh yes, I was once a person who suffered and stumbled, but having been through my own therapy, better yet, analysis and training, I am beyond ordinary human suffering. I have achieved 'mental health'"). Mystification enhances the power and idealization about the therapist. Myths about the attainment of what psychoanalysts called "the pure gold of mental health" characterized by impossible standards of independence, strength, and conflict-free functioning shame both the inevitably imperfect therapist and the patient.
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