The study of mental processes has proven to be of only limited value in helping people transform in the aftermath of trauma. Lasting change, rather than being primarily a psychological, top-down process occurs principally through bottom-up processing (where we learn to focus on physical/physiological sensations as they continuously evolve into perceptions, cognitions and decisions). (Peter Levine: In an Unspoken Voice, p.282 (2010))
One of the earliest clients referred to me at the Trauma Centre in Cape Town – a refugee from one of the Great Lakes countries in Central Africa - told me she had a worm in her brain and the medication for it had made her pregnant. Was this a fantasy, a metaphor, a delusion? Was she psychotic? Recently relocated from a UK practice in psychoanalytic psychotherapy, where one is frequently looking beyond the manifest content of a communication for what is being unconsciously imparted, I struggled with what this might mean. It wasn’t easy to make sense of what she was telling me – not only because language differences made it difficult for us to understand each other – but also because this issue was not the reason she had come to seek help from the Centre.
She wasn’t seeing well and thought she needed spectacles. She seemed to think I could assist her. I was gobsmacked. Why would someone come for counselling at a Trauma Centre to get glasses? She insisted that was why she was there, so I went downstairs to the receptionist and asked disbelievingly if this was something we did. Imagine my surprise when the answer was yes!
Trainee optometrists at the Cape Technikon nearby, had been given a grant to provide cheap glasses to clients of the Trauma Centre. My client was just going through the pretence of having a session with me in order to get affordable glasses! If I had ever nursed the idea that my attention was valuable and unique, this was surely a humbling antidote. However, sending her off satisfied with the referral she’d wanted did not rest easy with me. Had I missed something in this story? Was she trying to tell me something? Would I be letting her down if I let her go? I called a doctor friend that night. Yes, tapeworms in the brain – neurocysticercosis – was a reasonably well known condition . It can affect eyesight and some kinds of medication to get rid of the tapeworms can interfere with oral contraception.
Only one session!
Most trauma counselling mysteries, (and there were many mysteries for me in the beginning), were not so easily solved. Many clients would come having experienced a recent trauma – usually crime-related – and just want one session! I assumed that they would jump at the chance of having free counselling but I couldn’t have been more wrong. Many people returned to their usual modes of coping (not necessarily ideal states to my mind) after a couple of weeks. They did not want to have a session that would re-evoke the trauma. Then the Centre’s mostly unemployed or working class clients lived some distance away, so spending money on transport to get to the Centre was a luxury many could not afford.
After the release of political prisoners in 1990, the Cape Town Trauma Centre was set up with European funding to assist survivors of violence and torture. Between 1991 and 1994 the Centre welcomed, occasionally accommodated and oversaw the integration of returning exiles. Then it was involved in supporting the local victims at the Truth and Reconciliation Committee hearings. After the first democratic elections, South Africa opened its doors to refugees from all over Africa but services for them were embryonic. By the time I arrived in 1999, HIV infection, violent crime, gangsterism and bombings had become serious issues in the Western Cape. Partner organisations dealt with gender violence and HIV/AIDS. We were taking on clients who had experienced political or criminal violence or accidents that had resulted in bereavement. But it was never so clear-cut. For the increasing numbers of survivors of violent crime, we were supposed to be doing Critical Incident Stress Debriefing. Thankfully no-one checked up on me – I had no intention of doing anything that was called “debriefing” and I wasn’t terribly interested in finding out what it was. I turned out to be right because debriefing was later discredited except in specific situations but there was nevertheless much I needed to learn.
I very soon realised that it was important to remember that I am white and mostly English-speaking and it was particularly relevant when my clients were not white and were middle-aged or older. English is often a 2nd or 3rd language for Afrikaans or Xhosa speakers and it is the formal one that they have frequently had to use when speaking to their employer. So I was respectful and polite at reception and as informal as possible in the consulting room. Making a “fool” of myself or being silly was ideal, and I found lots of ways to do this, mostly by demonstrating ways to regulate affect. After a few years I actually had a staged single session that I implemented for adult onset trauma, which involved normalising symptoms, imparting tools for self-regulation, loaning confidence and even explaining very simply how elegantly the client’s brain was performing in dealing with a life-threatening situation. For instance, I knew when I saw a group of garbage workers who had discovered the dead body of a baby in the rubbish that no white woman had ever told them how brilliantly their brains functioned. Doing this was as healing for me as it was for them. I had come back to the country of my birth to make a contribution and to make reparation for the privileges I had enjoyed and of which others were deprived. I am very grateful for the many opportunities I have had to do this which once again originate from my privileged position.
But what is adult onset trauma in the contexts in which most people live in the Cape Peninsula? There is really no such thing except perhaps in middle-class neighbourhoods. Anyone living in a township lives a life exposed to continuous violence, veering from one crisis to the next. And how do they cope? They dissociate, they have physical symptoms or they are addicted to alcohol or drugs, and frequently act out violently themselves. So this is another reason people only came for one session. I suppose that once they could get back to dissociating, that session with the strange white woman who had told them to yawn and shake and showed them how, was relegated to the realm of the exotic – the way some people feel about visiting a foreign country. Nevertheless, I got enough feedback to know that what I was doing was helpful at times.
On the other hand middle-class people appeared to be less resilient and readily came for more than one session if it was suggested. They had more resources to do so, and were keen to recover a level of functioning that takes longer than perhaps dissociating does.
Telling people what to do.
I was lucky to have a supervisor who had been a Professor of Social Work and who had counselled South Africans through many of the country’s most turbulent times. He introduced me to the realities of people’s lives. He told me that as a trauma counsellor you have to talk quite a lot particularly in the first session and he was referring to the amount of psycho-education that is required. I wasn’t used to this. As I grew into it I found I enjoyed it – in fact I loved telling people what to do! Something I never did as a therapist, beyond the occasional suggestion. My previous working life started to seem so very passive to me.
Being an advocate
I began to discover previously hidden talents in myself. One day three refugees came to intake because a fellow countryman had died and his body was being held in a private mortuary. They didn’t have the financial resources to get the body released for burial. The owner wanted R500. I called him up and managed to bargain him down to R150, which the men had said they could afford. I felt very pleased with myself. In my youth, my mother had often bargained at stores or markets, much to my embarrassment. Now I felt she would be really proud of me. I discovered the kind of clout one has with the backing of an organisation with a good reputation. You could get things done and for me, it turned out to be getting refugees treated more humanely in banks, in hospitals, at Home Affairs where refugees apply for documentation, and at work.
Psychotherapists are used to having all kinds of roles transferred onto them – parents, doctors, dentists and teachers being the most common. But the role of preacher was a bit unusual for me. I grew up in the Jewish community in South Africa but I had no idea how important religion is to most people. Early on I was asked to co-facilitate a storytelling group of a large organisation of victims of apartheid human rights violations. Every meeting would start and end with singing and prayer. Someone in the group would be moved to take up the praying out loud. I had always been scared to speak in front of large groups without any notes so I found the spontaneity of this very impressive. And sure enough, there came a day when the group was small and nobody else seemed to take up the praying, when I felt it was incumbent on me to do it. I prayed that people would be able to trust us with their difficult stories, that they would be able to express their feelings and that we would be able to listen. To my amazement this seemed to be acceptable.
Individual clients told me that they prayed when they were held up at gunpoint or were being held hostage in their car after a hijacking. And of course because they had survived and were now sitting in front of me, God had listened to their prayers. When asked what comforts them in difficult times, women invariably said that going to church and praying with others did it for them. A bereaved family group once asked me to pray with them at the end of the session, meaning that I should be the one to speak. On that occasion, the intern who was sitting in on the session came to my rescue.
The Great Leap Forward
Then in 2004, Berthold Gersons, a Dutch psychiatrist and traumatologist, travelled to Cape Town with Merle Friedman, founder of the South African Institute of Traumatic Stress. I missed most of his talk at the University of Cape Town but during the discussion I picked up that there was evidence that just telling the story of a traumatic incident re-traumatizes the survivor, and that this should not be done without some form of processing. Merle Friedman mentioned bilateral stimulation. I felt embarrassed on behalf of the Trauma Centre. At the time we didn’t offer anything other than some kind of talking therapy according to a model developed at the University of the Witwatersrand. When a course in EMDR was offered by Sandy Richman that winter I signed up. I wasn’t too impressed until I piloted it with my colleagues. Then I decided to try it with a client who had sought help but hadn’t made much progress in two years of counselling. She had received a serious death threat while trying to root out corruption as the Director of a rural health facility. EMDR allowed her to acknowledge the early roots of her trauma when threatened with annihilation as a baby and she began to recover.
Although most of our clients came with acute stress disorder and therefore were not potential EMDR clients, I used the technique very successfully with some refugees who had PTSD. For many of the others I developed the single session I described earlier, in which the client did not have to tell me the story unless they wanted to.
On reflection, my transition from a psychoanalytic psychotherapy practice in London to being a trauma counsellor in South Africa involved engaging in new contexts and learning and developing new therapeutic processes. It required a more creative and flexible approach – both in how I listened and also in how I responded. It did not seem as important to sense the unconscious communications behind people’s words or embodied feelings, as it was to be able to witness and contain the often terrible realities people contend with on a daily basis. The after-effects of undergoing trauma are experienced in the non-verbal realm of bodily sensations, hormonal quickening and flashbacks which are hard to eradicate. So what would be the therapeutic aim of a single session? It wouldn’t be to make a relationship in which the client might eventually feel safe enough to explore their early attachments which may have been infused with trauma. To my mind, the emphasis had to be on empowering clients with as much knowledge as possible (both experiential and cognitive) to enable them to self-regulate their bodily and emotional states. Faced with so few resources, this seemed the most effective way to enable people to take charge of their own recovery, mourn their losses and if not able to fully reconnect with their former selves, at least to construct something meaningful out of their experience.