As a retired psychiatrist reflecting on a life of treating broken bodies, spirits and souls, I have had the extraordinary privilege to learn from my past experience, both successes and failures, and identify the most basic fundamental ingredients essential to helping people heal.
They boil down to:
[1] Establishing a genuine therapeutic alliance, which necessarily involves congruence and empathic understanding on the part of the therapist.
[2] Installing (or restoring) faith and hope in the client.
In all the cases of successful suicide by patients that I am aware of, the common threads were the client being overwhelmed by loss of hope, and the failure of the therapist to instill or restore hope in the client. And all too often, when a patient successfully committed suicide, it was clear that they felt that their therapist had lost hope in their recovery too. It is a great sadness that therapists can and do lost hope in just that way.
We must do better as therapists, and it is possible to do so. I believe the key point is to understand that hopelessness, manifesting as depression, suicidal ideation or suicide attempts does not happen in a vacuum. Serotonin alone will not eliminate the risk of suicide if the underlying cause is not addressed. That underlying cause, in cases of abuse, is overwhelming fear. The dyad of hope and fear must be clearly understood.
In cases of Complex PTSD, the trauma is overwhelmingly powerful, leaving the client terrified. Being terrified, without any safe haven from the abuser, leads to hopelessness which must be recognized and addressed. For those suffering from Complex PTSD, the hopelessness is intimately tied to and a product of that fear. For abuse survivors, the fear is often tied to the direct inflicting of pain, physical, sexual, emotional, coupled with the repeated assertion that no one will believe that the survivor has been abused.
The patient hopes the abuse will stop, they fear it will not. They hope that someone will believe them, they fear no one will. They hope that if they act is whatever way the abuser demands, that they will be spared and they are not. Fear is the flip side of hope.
While the psychiatrist assesses the patient, the patient assesses the psychiatrist. The patient hopes the psychiatrist will understand, and fears that they won’t. When those with complex PTSD have a long history of ineffective and somewhat destructive relationships with the mental health system, they fear – often correctly – that everything they had been programmed to believe about no one believing them is true. In this way, the dichotomy of hope and fear is brought into the therapeutic relationship from the very beginning.
To combat this and strengthen the therapeutic alliance, the psychiatrist must effectively communicate that the therapeutic journey will undermine that foundation of fear. To avoid scaring the patient, one must encourage them that taking the smallest steps toward healing are the safest – particularly at the start of therapy. Each time any fear is undermined, a glimmer of hope emerges. That is the nature of the relationship of hope and fear to communicate to the patient.
Time and time again in my own practise, I was reminded that little gestures are the crucial building blocks of healing. Healing does not come from grand breakthroughs of revelations or enlightenment. It is built on small building blocks even at the level of regaining the control of one comfortable breath.
Offer hope by helping the patient make tiny, achievable goals with each therapeutic encounter. Each session with the patient that enables them to exert some control, even in a very limited way, over the runaway flashback symptoms is a critical “baby step” in healing.
As related in Chapter 1 of my book “Engaging Multiple Personalities”, I told Joan in our first session that my aim was to help her feel just a little better each session. According to her, this was a most powerful suggestion that propelled her toward healing when she was in the darkest period of her life, having almost given up as a result of the total dis-empowerment of PTSD.
In another case, my last patient of the day calmly told me that she was going to kill herself after seeing me. There was no doubt in my mind that she was simply stating her intention, and that it was not an empty threat or desire for attention. There was literally only one hour to intervene.
I related to the angry part of her, understanding that the source of the anger was the deep hurt of past trauma. I helped her connect to the anger as a source of valuable energy that could be redirected to her healing. I gave her hope that she could turn around the anger, the hate, and see that the best revenge was to overcome the trauma inflicted by the abuser by showing that the abuser had not succeeded in destroying her.
The best revenge is indeed to show the abusers that they failed to destroy the child. Many survivors of childhood abuse carry this sense of hope, of mission, to survive to tell the world that such abuse did happen. To stay alive, to fight for the future so that one could bear witness to such horrendous crimes. We need to change the world so that every child grows up nurtured, loved and protected from abuse.
