Strongly associated with the emotion of shame is the belief that others will judge us negatively, leading to a natural desire to hide what we are ashamed of from others. In therapy, this means that clients will often prefer not to talk with us about their traumas or even to disclose what has happened. We need to balance respecting this decision with giving an informed choice of effective treatments, many of which are trauma-focused.
Often, as we build a therapeutic relationship based on trust and acceptance, our clients realise that we will not reject or punish them, and become more willing to take the ‘leap of faith’ to confide in us. This in itself if a hugely powerful behavioural experiment: learning that another person can listen to something they find deeply shameful and still hold them in positive regard. We can aid this process in early sessions by attending to the therapeutic relationship – demonstrating warmth, empathy and respect in everything we say and do. Clients who expect to be rejected will be watching us for signs of condemnation, so we need to be very clear in our verbal and non-verbal communications that we are wholly on their side.
It can also help to talk explicitly about how to build trust. We explain that many of our clients struggle to trust us and that this is entirely understandable given their experiences. Sometimes we ask our clients to rate their level of trust in us on 0-100 scale. We ask what we can do that might help build the trust by another 10 points, and then keep the ratings under review every session. We endeavour to be transparent in all aspects of the therapy process (confidentiality, note-taking, drafting letters etc) and give our clients agency over every step – so they should never feel pushed, coerced or ‘blind-sided’. We make seeking feedback on the working relationship a standing agenda item, giving clients opportunities to let us know anything we say or do which reduces trust between us, then responding non-defensively and apologetically when we make mistakes.
We offer psychoeducation about PTSD in early sessions, explaining the role of trauma memories in maintaining the PTSD symptoms, including the problem of shame, which helps explain the rationale for why we talk about what happened. We also make it clear that we, as therapists, regularly hear about horrible traumatic experiences, and never judge our clients for what has happened or what they have done; our only goal is to help them recover from their PTSD.
There are parts of treatment that can progress without us talking about the traumas. For example, we can start work on reclaiming or rebuilding your life activities. If we know some triggers, we can work on trigger discrimination without talking about the trauma itself. Where dissociation is a problematic symptom, we can work on grounding techniques. If we have been able to do something useful in early sessions, it can build faith in the therapy process and us as a therapist enough to progress to more trauma-focused parts of treatment.
Sometimes, when we know the general type of trauma (e.g. sexual assault), we can also work on some of the associated beliefs without knowing the exact details of what happened (e.g. debunking rape myths). This may allow us to chip away at shame-related beliefs sufficiently for clients to test out telling us a bit more. For example, a military client was able to disclose that they had killed somebody in combat and felt ashamed of taking a life, but no further details. This information was enough to normalise the experience of killing in conflict, discuss moral injury, direct the client to others’ accounts of the experience, and do an imagery exercise where they disclosed the event to an imaginary moral authority.
We can also be flexible in how we get to trauma memories to suit an individual. For example, some people may be willing to complete a trauma checklist such as the LEC-5, or to answer ‘yes’ or ‘no’ to a list of traumas that people commonly experience. Others will be more able to write down what has happened than to say it out loud. For example, one of our clients struggled to say what had happened to her but agreed to write it down, as long as she was not watched and only her therapist saw what she wrote. An early session was spent with her in a comfortable therapy room, alone with a cup of sugary tea, writing a brief account of her trauma, which her therapist was then allowed to read in silence. This meant that the therapist learned the source of her shame – she had been raped by two strangers as a young teenager after accepting a lift from them, and believed that others would think it was her fault because ‘everyone knows you don’t get in a car with strange men’. The next step, a survey of people’s reactions to this scenario, showed that most people were sympathetic to the young woman and did not believe she was to blame for the rape, even though she had got in the car. As her shame reduced, she was more able to talk to her therapist in detail about what had happened that day.
If, after all of these steps, the client still feels unable to talk about what has happened, we help them make an informed choice about how to progress in therapy. Non-trauma-focused treatments for PTSD are one option, although we are honest that the data suggests these are less effective forms of therapy. EMDR requires less verbal or written explication of the trauma memories than TF-CBTs, and there is even a ‘blind-to-therapist’ protocol. However this still requires the client to repeatedly bring trauma memories to mind in sessions, which itself can trigger shame. Some clients may choose not to continue with treatment for now; the key then is to give them a positive experience with us, and leave them feeling that they have been treated humanely and with respect in the hope that they will return when they feel ready.
Practice points
· Shame can make it difficult for our clients to disclose their traumatic experiences
· Building the therapeutic relationship can make this easier
· Trust and ways to build it can be explicitly discussed
· Psychoeducation about PTSD helps build a rationale for trauma-focused work
· Other parts of treatment can progress without full disclosure of the trauma
· Shame-related beliefs can also be addressed without knowing the details of the trauma
· Different options for disclosing trauma memories can be explored
· If these steps do not enable discussion of the traumatic event, other treatment options can be considered