The article presents the specificities of the person-centered psychotherapy (PCP) intervention when the subject is exposed to a situation with psychotraumatogenic potential, the basic conditions postulated by Carl Rogers: empathic understanding, unconditioned positive regard, congruence and the steps that facilitates symbolization of traumatic experience by family members, especially children. The hypothesis of this research is that support of a framework, of a secure environment provides much more adequate and complete symbolization of traumatic experience, such symbolization mobilizing thus coping strategies more flexible and more adapted to the situation.
Frightening things happen to children all the time, either if they fall from a tree or if they get stung or if their favourite grandparent dies. In most cases, children are scared, sad, angry or confused for an interval of time. However, they gain strength from their inner power and carry on with a sort of confidence that they can cope with harder situations when they occur. They may even happen to become depressive again for a while when something reminds them of the past. But trouble, grief or panic do not interfere with their day-to-day life. Feeling traumatised is a different way of being scared. When anyone, either young or old, faces a real threat or a perceived one to his or her life, certain psychological changes are triggered automatically: the pulse rate goes up and stress hormones flow into the blood stream.
Certain tell-tale signs are easy to signal. Toddlers cry and cling to their mothers more than usual. Pre-school children regress to pants-soiling, thumb-sucking or stuttering.Schoolchildren develop an inability to focus on their homework and complain of headache, stomachache, nausea or nightmares.They can even persuade themselves that the terrible incident they have been through is going to occur again and, even worse, that they were responsible for its occuring in the first place. However, since many symptoms of the trauma are less obvious, they are easy to ignore or they are erroneousy interpreted – the child who keeps himself to himself, with a shocked countenance, will not be noticed in the same way as a child who wakes up screaming in the middle of the night.
Why are some children able to stand – even to overcome – shocking events, whereas others are devastated by them? Those who work with traumatised children have learned that, up to a certain limit, the ability to withstand high stress is correlated with their inherent structure. Some small children who are calmer and more relaxed are also simply more resilient. That is the case of children brought up within families in which the general attitude is loving and kind or the case of those who have found a teacher, a coach or some relative to take care of them or to believe in them. The child’s age, as well as the duration and the source of truma, also affect that child’s ability to face the situation.
On broaching the subject of crisis handling which occurs as a consequence of exposure to a traumatising event, one opens a vast domain. It is vast due to the diversity of triggering factors and due to the particular character of each person’s reactions on facing that situation. Yet, in all that diversity, one can also find some common ground: in fact, people try by so many different means to regain the feeling of having the situation in control, the feeling of being safe again.
Given that the domain is so vast, I shall restrict the area to which I intend to refer. From the person-centered psychotherapy perspective, I shall present theoretical and practical aspects regarding the crisis situation occurring in a family when one parent suddenly falls ill. The sudden occurrence of the illness is the triggering factor, even if in general I am tempted to pay more attention to subjective reactions to triggering factors, their intensity, their duration, their value in the system within which they act (in this case, what changes in the family when a parent is ill, what is lost, what must be reorganised in this system).
What is a crisis?
I shall define this domain again and I hereby propose a definition of crisis from the perspective of person-centered theory:
“A crisis is a state of extreme incongruence. The person is incapable of integrating the feelings of high intensity suddenly occuring which bear in them the imminence of danger. S/He is in a state of great vulnerability in which psychological disorganisation is possible at any moment.” (Carl Rogers, 1959). The person reaches a state of tempestuous inner captivity, of fear, helplessness, emotional confusion in which her/his defense strategies do not cope with the situation.
Traumatic crises are triggered by unforseen sudden events, by incidents whereby a loss occurs or which threaten the person’s identity.
When speaking about a crisis, in most cases we mean an acute reaction to stress, an adaptation disorder, a post-traumatic stress disorder. These are well-defined categories, described in stages of manifestation and intervention which I shall not refer to now.
But not everyone has an acute reaction to stress, not everyone suffers a post-traumatic stress disorder (and it is very well that not everybody does), yet numerous people have traumatic states which trigger psychological sufferance and which in time lead to personality changes, especially if these states occured early on in childhood. These are the ones that I shall refer to further on, as well as those for whom a certain interval of time has elapsed since exposure to the traumatic situation and in whose case the reaction remains at a subclinical level, but the trauma’s effect does not fade out either. This is where the role of primary psychoprophilaxy comes in, in intervention in order to anticipate effects.
Person Centered Psychoterapy (PCP) literature refers to traumatic state perceived emotionally and bodily, where it remains like an imprint upon memory. The body reacts strongly diring crises and is exposed to danger. It often is the main bearer of symptoms. Those states threaten to become overwhelming, they are too intense, they induce fear and massive panic. Subjects often describe a great distance to their own feelings and to other people. The feeling is of emptiness and indifference: “I grow silent, I am paralysed, everything is so far away, I cannot reach anyone.” In fact, there intervenes a dissociation mechanism with a defense role. And connection with feelings, with states, is difficult.
Due to the subjects’ inability to understand this situation, the self-esteem feeling is also progressively eroded. This situation can sometimes lead these people to be aggressive with others, but also with themselves.
When the state is misunderstood, it can sometimes manifest itself in symptoms such as restlessness and sleeplessness, vegetative lability, waves of perspiration and tremors, mood variations and depression.
Luc Ciompi (1993) showed that most crises are accompanied by somatic sufferance. Possible somatic symptoms are very varied and different in point of difficulty. They can include – in islation or in combinations – perturbation of the respiratory system, of the blood circulatory system, of the digestive system and of the uro-genital system. Further on there may occur dermatological perturbations, migraine, a general reduction of resistance, infections, fatigue.
A person in a state of crisis is preoccupied to keep away from her/his conscience the state that threatens her/his concept of self.
The traumatic state can be very obvious, accompanied by sleep troubles, frenzy, vegetative perturbations and therefore it can be perceptible from the outside or it can be “lived silently”. There can occur nightmares, terrible fears, sadness, profound pain that can remain unnoticed from the outside or made unnoticed for various reasons, which are equally important for us.
What is the danger of the traumatic state?
The hypothesis which I now have concerning the situation which I handle, namely an ill parent in the family, is that the person doen not tell the family what emotions, states, fears, worries s/he has, because among the nearest and dearest there is no “room to tell such things” or no “room for such tidings to be received” in such a way as the person would want them to be, that is in that way which would bring about comfort and safety (either because a child protects his/her trustful parent whom s/he sees in a state of some distress, or because a parent hinted on other occasions that certain discussions about emotions are not to be initiated).
And these are states accompanied by traumatic states which, in time, change something in the individual’s personality. That is, they “erode” his/her self-confidence, the confidence with which s/he copes with life in general, his/her self-esteem, his/her well-being, his/her inner comfort or, as one might put it differently, his/her quality of life.
And precisely because we do not know when and where such things occur, I maintain that psycho-prophilactic intervention has a huge role in maintaining a state of mental health by improving access to such states and by making the family environment more homely, more apt to digest, to metabolise, to accomodate such states.
The one who makes her/his traumatic state visible, by this very means as well shows that s/he has the power to struggle, to demand resources and help, to give hints that s/he needs something from the outside.
The one who bears this state in silence cannot afford to do even that, cannot even manifest this state, since that would mean that s/he were asking for something, and “asking” might be too much. S/He tries to cope with this situation on her/his own. But at what cost?
Eva Maria Biermann-Ratjen (2001) demonstrates that there are some dangers for personality development, especially when those traumatic states occur during personality formation, that is in the case of children, which can lead to:
- a permanent stagnation in personal development
- the defense against emotional states becomes regular and generalised.
What begins as a limited form of anaesthesia can turn into emotional withdrawal and into a state of numbness in which emotional states of any kind are ignored. And so the person protects herself/himself against a potential occurrence of a painful state.
What begins as an impulse to escape danger can turn into excessive vigilence, and the person avoids any new emotional state or is in a state of alert to escape any kind of new feeling.
Herman in 1993 stated that “traumatising events cause profound long-term changes in physiological emotion, in feelings, in perception, in memory. Besides, sometimes, these functions which normally synchronise are separated from one another after a traumatising event. The traumatised one has, for instance, intense emotions, but cannot precisely remember the incident, or remembers every detail, but does not feel anything regarding those events. S/He can feel irritated permanently and very much on the lookout, but without knowing why. Frequently, the connections are lost between the traumatic symptoms and their triggering factors, and the symptoms become individualised.”
What does psycho-prophilactic intervention target?
Psycho-prophilactic intervention from the perspective of person-centered approach hinges on creating within the family an environment more open towards states such as: fear, powerlessness, insecurity, inner pain, helplessness, embarrassment, anger. If these states are empathetically understood and unconditionally, positively accepted, that means that they can be integrated in one’s concept of self as: “I may also be powerless, afraid, insecure, scared, helpless,” and being that way is all right, just as it is understood that “there is room for that, I can open up in the family, communication is possible”. That is, there is room for one to speak openly about what one experiences inside and there is no need to send this message indirectly, as a hint or as a symptom. There is room for: fear, powerlessness, embarrassment, inferiority, concern, envy, insecurity, lack of confidence. Thus, a person will mobilise her/his resources in order to carry on. S/He mobilises her/his own resources, but also becomes more open towards seeing them at people outside and towards learning from them, and thus will have larger access to resources in order to develop.
There is a vicious circle here: if the aforementioned do not happen in a family, this can lead to more easily perceiving a situation as being traumatic because that person more easily gets to that inner conflict between what s/he feels and what s/he knows s/he may feel according to her/his conception of self. However, if one has a better relationship with embarrassment, with insecurity, with powerlessness, with fear, one can handle them better emotionally and one will perceive those situations more seldom as threatening.
What does psycho-therapeutic intervention target?
The aim of psycho-therapeutic intervention in the crisis situation is enhancing the feeling of security offering a time perspective, with a view to mobilising the inner resources in order to cope with the situation. A crisis takes time to metabolise and for this thing to happen a good environment is needed. And by this good environment I mean an environment mindful of signals.
The aim of psychotherapeutic intervention in a trauma is to annihilate dissociation.
Namely, thoughts, representations, words, feelings and bodily sensations which describe the traumatic experience must be collected in totality. Where there are intrusions, they must turn to memories. Specifically, the traumatic experience must be fully symbolised as a personal experience. Only then can it be included in the concept of self and its re-emergence in the conscience can no longer be a threat to the latter.
Carl Rogers (1959) states that, for the change in personality to occur, it is necessary to constantly ensure the following conditions in therapy:
- Two persons must be in psychological contact.
- The first person, whom we shall call the client, is in a state of incongruence, being vulnerable or anxious.
- The second person, whom we shall call the therapist, is congruent in the relationship.
- The therapist experiences an attitude of positive unconditional regard towards the client.
- The therapist experiences an empathetic understanding towards the client’s inner reference frame.
- The client perceives, at least on a minimal level, the therapist’s positive unconditional acceptance and the empathetic understanding. Therefore the therapist must communicate these aspects at least at a minimal level.
If these conditions are fulfilled, then there will occur a process which will include certain characteristic elements. If this process runs its course, then most definitely the change of personality and of behaviour will take place.
The general aim of psychotherapy after a psycho-trauma is that each event should be remembered through emotions. From the despair of powerlessness the subject should move on to a bearable sadness regarding the losses and the sufferance s/he has undergone, and the intrusions should become memories.
Namely, this entails annihilating the need for dissociation in any of its forms, as well as the annihilation of chronical incongruency and the increase of the degree of congruence between emotional states and the concept of self (the opposite of the crisis definition).
Michaela Huber in 1995 spoke about “the synthesis of trauma” and the ongoing inclusion of emotional states in one’s own context of experience. Thus, it is important for the therapist to explain that, in case of trauma re-activation, by techniques of exposure to trauma, the affects and sensations are more impetuous than in the traumatic situation itself, in which the person was profoundly dissociated.
At present, what the therapist wants to detect, what the therapist obtains by questions concerning details or what the therapist exploits empathetically during an anamnesis or during a short-term remininiscence regarding the trauma are considered to be medical errors. Exposure to trauma and working with it necessitate a thoroguh training and a clear therapeutical framework.
Generally, medical services are highly specialised and when a person approaches such specialties as a patient, the medical personnel focuses efforts on assuring the medical care of that ill person.
Only family medicine addresses a person and bears in mind that the person is part of a system, but even here the intervention is individualised and does not take into account the dynamics within the system.
Consequently, situations of severe illness in the family have effects on the family’s other members which can remain undetected, which are paid no attention to, and they may become visible later in time, when one must already face their consequences and when still other specialised medical services are called for.
That is why I believe it is important to orient attention towards the entire system which an ill parent is part of and, especially, towards the children.
Generally, when a crisis situation occurs in the family, adults orient all their efforts towards the ill person and towards maintaining the family’s general organisation at a reasonable functioning level. Children are provided with the basic needs (food, physical security) without anyone giving too much thought to the emotional impact of the traumatic event on them.
It is important for the trustworthy parent and for the children to be oriented towards services that will offer them counseling for the crisis situation triggered by a psycho-trauma. It is a prophilactic service that reduces the influence of trauma-inducing factors from the present for later on. And thus the quality of life at present increases.
To that effect, those who first come into contact with ill people and with their families can:
- Explain the importance of recourse to specialised services.
- Explain to the families that the event also has an impact on the child’s emotional life.
- Explain that this impact, the intensity of which we have no knowledge about at present, can have certain consequences in the medium run and in the long run.
- Explain that personal reactivity is very different from person to person.
- Explain that these consequences can be forseen only after an evaluation made by specialists and after monitoring the child’s evolution for some time.
- Explain that psychological health reflects in a person’s quality of life.
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