Going Back?

[Sandstone]

Another chapter in my attempt to get a decent long-term T.
The NHS are still procrastinating. I am told they have accepted the expert assessment that I am in need of long term therapy twice a week, but they are still finding excuses not to take that to the funding panel. I have gone direct to the local expert organisation they would probably use, and asked if I can start therapy now, paying for myself but hoping the NHS will take over.

That organisation has suggested that I go back to T3, who I saw in 2013 / 2014. She is highly experienced, well respected and I liked her. Yet we had a bad (suicidal?) ending. I felt immediate resistance to the suggestion and attributed it to my sense of failure, but suspected there was more.

Looking back, I see I wrote in early 2014
"I have a private therapist, with a psychoanalytic approach, who I've found very helpful, supportive and blessedly humorous. Working with her is helping me to understand where my harsh self view comes from, and why I was the perfect victim. But we aren't doing the specific trauma work I'd like to do, neither the stabilisation nor the processing."

and six months later
"I did like and trust the woman I was seeing, but that didn't stop me O/D-ing and crashing the car when we went near the traumas. We agreed it was too risky to continue, because as she said she had nowhere to admit me and keep me safe.

I sent her a document outlining the stabilisation stage of work, and she responded "What the author describes would seem to be standard practical advice to therapists working in this field, ...."

So what do I do? If it's standard, why didn't she do it? Why has no-one done it, and why did no-one support me? I've had six months of nothing, and in some ways I'm more stable, but the box is open and won't be closed. If it's too dangerous to work through it, am I destined to remain in this limbo for the rest of my life? "

I'm not sure what to do. I have known since 2013 that the stabilisation stage of work is missing, and I've told everyone, but they seem to skip over it. I can believe that going back to T3 would work from the relationship/attachment side of things, but what about the stabilisation, and the whole three phase approach to therapy which I want to follow? That was why I wanted to go through a trauma and dissociation specialist organisation. Perhaps my history and the assessment report indicate that the relationship is all that matters? I'm not sure though. I think I need to be assured that safety and stability are top of the agenda.

 

[James McGregor]

Another chapter in my attempt to get a decent long-term T.
The NHS are still procrastinating. I am to...

i fell your pain, i too know the suffering of the nhs getting their act together. They will do anything to avoid providing the right mental health care - even when it is them who recommended it! Years ago i was looking for funding to get the level of care they said i needed but couldnt provide, in the end they rejected their own recomendations. I decided to go private myself, i could only afford it twice a month. Now im back with the nhs, got a decent psychiatrist for once, im seeing her twice a month for a year - still not ideal but as good as its going to get. Sadly i have little faith in the nhs, their mental health approach is disgusting, i feel for you - i do know how infuriating it is

 

[digger]

I'm not sure though. I think I need to be assured that safety and stability are top of the agenda.

Yeah, I think this is extremely important for you to establish with whoever you go on to work with - whether that be someone you've worked with before, or someone new. I think it needs to be top of the agenda from the start and the importance of that to you to be stressed.
I guess my next step would be to approach T3 and, before committing to,or thinking about, anything else, just getting feedback from her on how she thinks she would propose to go about better managing that with you this time around.

 

[James McGregor]

Another chapter in my attempt to get a decent long-term T.
The NHS are still procrastinating. I am to...

One thing to add, ive seen private therapists and those in the NHS - and while im sure there are very good senior therapists, ive since found out a lot of people who we believe to be therapists - are actually mental health nurses. They may be very experienced and im sure do a good job but they are NOT therapists. Seeing people in the private industry really highlights this, they are miles apart in their skillset and attitude. Ive seen a couple over the years in the nhs that i would consider proper therapists, the rest - well im surprised they can get themselves dressed in the morning, they are useless!

 

[barefoot]

I agree with @digger - I'd be inclined to get in touch with T3 if the relationship/attachment side of things was very positive and something you think you would return to with her and find out from her whether she can work in a way that you're looking for, in terms of the three stages of work and the stabilisation focus etc.

You could either say, "This is what I'm looking to do and these are the things that are most important to me...do you think you can help with that?" And, if she says she can, you can probe a little deeper with her to see how specifically she would approach this work with you. And, if she doesn't think she can, she may be able to recommend someone else who she thinks a) would be able to do it and b) is someone who she thinks you will like and get on with.

Or you could just start by giving her an update on current diagnoses symptoms etc and asking her how she would approach working with you.

i.e. depends on whether you want to lead with asking for what you think you need and then asking if she can deliver that. Or whether you instead ask what her approach would be and see if that matches what you have in mind.

I can see arguments for/against both those ways round.

A conversation with her certainly can't hurt and could be really helpful - whether you end up working with her again or not.

Good luck!

 

[Sandstone]

I left it with them that they would contact T3, to see if she is currently taking new clients and if she would be willing to work with me again. I'm determined to go ahead with positivity. I know that she was very good at enabling a relationship and that she understood me well. She defines herself as an Attachment-based Psychoanalytic Psychotherapist, so I would expect her to be skilled at that. I recall her telling me that she hoped eventually the things we shared would overwrite my old negative messages, and I can see that some have. Looking at her profile photo can feel that warmth still.

The assessment I had recommends attachment based psychotherapy, and I know. this is a sensible way ahead. Yet I still feel resistance
I have three possible reasons in mind.

1. Simply my Dismissive - Avoidant attachment style. When faced with it, perhaps I'm trying to escape the threat that T3's warmth represents.
2. Fear of going back a) simply the crawling back with my tail between my legs feeling. I know she would not see it like that and would not want me to either, but it is there b) a sort of chronological dissociation. Once I move on from anything in my life I shut the door on it and it is gone.
   
3. Safety. Could be as simple as fearing for my life. I believe I need to talk about my traumas, but I know there is that aspect that thinks it is safer to be dead than speak.

After the OD/crash, she offered to keep working with me , without going into the traumas. I thought that was impossible - how could we avoid the herd of elephants trampolining in the corner of the room? I'm still not sure if she can equip me to do that safely, and if she can, why did she not before? She recognised and warned of the danger, though not the scale of it, but gave me no tools beyond the relationship to contain that danger. There was long list of other stressors at the time and especially the side-effects of the Duloxetine that made it worse, and it has taken until T5 for anyone to identify with me just how far I dissociate from the distress until it bursts though explosively. I know more about myself and more about what I need, but I don't know if it is enough.

 

[barefoot]

I think this sounds like a promising step @Sandstone

Knowing more about yourself and what you need is huge, I think. Whether it is "enough"? I'm not sure I really know what you mean by that...? Enough to keep you safe/stable, do you mean? I think, just on quite a basic level, that knowing those things puts you in a much stronger, more informed, more empowered and potentially safer position than not knowing them.

That said, I still think it is absolutely crucial that, if you do end up seeing T3 again, you mention your concerns about what happened when you ended the work before (the OD/crash) and how she can work with you and equip you this time so that you don't have a repeat performance.

I have a similar thing about how therapy can work/what is the point if we're not talking directly about traumas. It is possible, I now think, to still do good, useful work with the traumas held as a context but without diving deep into the detail of them.

I suppose it is perhaps also worth considering whether talking in detail directly about your traumas will be helpful. I know my therapist has said that, for some people, it is not. For instance, she has said that it is not always beneficial for people who have been sexually assaulted to talk through every detail of the event. It may simply prove to be too distressing, retraumatising and de-stabilising for them to keep reliving it by talking about it in therapy, so that more damage is done by getting them to engage directly with it. She can still work with those people and they are still working on the trauma to some extent - and working on the aftermath/consequences of the event. But it isn't a deep dive straight into the goo of what actually happened.

Hope T3 turns out to be a positive way forward for you after all this time of waiting and being messed around!

Actually, I've just re-read and I don't think my comments about talking about trauma really address what you were meaning. Sorry - head is a little fuzzy today!

 

[Suzetig]

In thinking about the 3 stage process you mention are you referring to the model advocated by Judith Herman? It s a good model and aspects of it are present in most types of therapy that work with trauma - maybe not laid out in clear explicit steps, but there nonetheless.

If you read her book trauma and recovery it types trauma according to levels of resilience, extent etc and does say that for people with complex trauma and no real secure attachment patter that old fashioned relational therapy - a therapeutic relationship - is the right approach. My T is a trauma T, she hasn't taken a traditional 3 stage approach with me but when I look back I can see her working on stabilisation, processing trauma and moving forward but it's been more like a spiral than a straight line.

There have been times (months at a time) where we've talked around trauma or every day stressors, times of real intensity where I've delved into the impact trauma has on how I see myself (much much more painful than actually talking about the details of the trauma). And she's worked at my pace so I never really get too triggered because I'm in control.

I wonder if your T3 felt that kind of process would work better for you? I don't think a straight 3 step process works for all but the most straightforward trauma. Stabilisation keeps needing work because each layer of work reveals something painful and destabilising, talking about the same trauma from different angles processes it differently and moving forward changes as we grow. I honestly don't think there's a discrete piece of stabilisation that keeps us stable for always or a magic pill - it's slow long term work due some people.

 

[Sandstone]

I don't know If I am overly wedded to the idea that "processing trauma" is the holy grail of therapy for PTSD and also attracted to anything that offers a structure. I haven't read much of Herman, so I don't know what she recommends. My thinking is around the ISSTD Guidelines at Link Removed

Over the past two decades, the consensus of experts is that complex
trauma-related disorders—including DID—are most appropriately treated in
sequenced stages. As early as the late 19th century, Pierre Janet advocated a
phase-oriented treatment for dissociative disorders (see D. Brown, Scheflin,
& Hammond, 1998; Van der Hart, Brown, & Van der Kolk, 1989). The most
common structure across the field consists of three phases or stages:
1. Establishing safety, stabilization, and symptom reduction;
2. Confronting, working through, and integrating traumatic memories; and
3. Identity integration and rehabilitation.
(see D. Brown et al., 1998; Chu, 1998; Courtois, 1999; Courtois, Ford, &
Cloitre, 2009; Herman, 1992b; R. P. Kluft, 1993a; Steele, Van der Hart, &
Nijenhuis, 2001, 2005; Van der Hart et al., 2006; Van der Hart, Van der Kolk,
& Boon, 1998). The writings of R. P. Kluft (1993a), Steele et al. (2005),
and Van der Hart et al. (2006), among others, address many of the specific
considerations in the phase-oriented treatment of DID and other dissociative disorders

but I've read that recommendation in so many places.

I'm still trying to unpick whether my instinctive resistance has any foundation. It could equally be fear of getting back into it all. I'm confused.

 

[Suzetig]

It is the basic model for trauma work but when you have many different trauma or developmental trauma it doesn't really work in such discrete stages. Instead it's like peeling an onion - you're stable enough to do this bit, you hit a bit that destabilises you, do some more work on emotional regulation, are able to do the next bit, hit a bit that destabilises you, take a while in therapy to catch your breath again, do some stabilisation work, be ok to do the next bit etc etc.

So, you may do some safety work that lets you talk about X but Y is too difficult, in talking through and around X you start to build enough emotional regulation to start thinking about Y without dissociating, eventually you can mention Y and X feels like part of your story instead of being a traumatic memory. Are there things you couldn't talk about in T that you can now? Not necessarily trauma details but anything that used to be too distressing but now is ok? You may not remember when or how it became ok but it doesn't trigger you in the way it once did - at which point I feel the memory or thing has been "processed". Basically therapy should slowly expand the window of tolerance you have for talking about trauma. For me that process has been years long and there are things I still can't talk about - interestingly enough not so much the details of some of my trauma. In fact we don't talk in huge detail about my trauma as such, that's been interwoven with the impact on me, how I cope day to day and where we do talk in detail it's because the detail is important to whatever it is we are taking about.

I would highly recommend Judith Hermans book Trauma and Recovery to you. In it she outlines the 3 stage approach you're talking about and that comes recommended everywhere but she also gives good examples of what that looks like in practice and particularly looks at what stabilisation and safety might look like and places it in the therapeutic relationship.

There's no holy grail of trauma processing and even if you found someone who took a strictly linear 3 stage approach with you, you'd still struggle with dissociation because I think (just my opinion) that you're trying to go too fast in processing trauma before you're ready emotionally and psychologically.

 

[digger]

With regards the three stage approach, I have found this to be more my experience...

The consensus of experts is that phase-oriented treatment is most effective. The three stages most commonly used are:

1. Establishing safety, stabilisation and symptom reduction.
2. Working through and integrating traumatic memories.
3. Integration and rehabilitation.

In reality, there is unlikely to be a linear progression through these three stages: more commonly the work will spiral through each phase, with a frequent need to return to stabilisation work during the middle and later stages.

Link Removed

I haven't had a set structure to work to as such, my T *seems* to work more organically, but looking back I can see clearly that the work has been based on this framework, just not in such a linear pattern as the model looks on paper. I have needed to return to safety and stabilisation many times over.

 

[barefoot]

I agree with @Suzetig and @digger - in my experience with therapy I can see that the three stages have been present but not in a straightforward, linear order. I think that's part of the reason why progress can be slow and how it can sometimes feel like one step forwards, three steps back. Because it hasn't been a case of "ok, stabilisation is done, now let's crack on and do the work" as a one-time process. We have frequently had to return to stabilisation at various points, as we dig deeper or as new parts of the work crop up or just if there are more here and now stressors going on in my life, which means I am dysregulated.

I've just ordered that Judith Herman book - thanks for the rec @Suzetig