1) How can a therapist help someone struggling with poverty, trauma when they don't feel safe in their environment?
I think, as far as the therapeutic environment, it starts in setting the tone. "This is your time to do with as you wish. My job is to be a guide." Also encouraging them to advocate for themselves, set good boundaries, and speak up. I often tell my newbies "for people in therapy it's hard to speak up. If I say that I'm available outside of session, I mean it. Don't let that thought that you are a burden get in the way of reaching out to me because you're not." And processing when it happens: "You said last Monday was hard. You struggled all day. What got in the way of reaching out for a 15 minute phone call to ease your suffering, and how can we change that in the future?" This also sets the tone for cost and poverty conversations. I'm out of network and cash pay, but that doesn't mean that I don't have room for pro-bono, low cost, or negotiated fees. For me, that's part of why I AM cash pay, to offer myself the financial freedom to be more available.
A big part of this comes from being a good therapist. A big part of our job is to be aware and actively listening. If we know that a client is in a poverty situation, is struggling with finances, or with an emotionally unsafe environment that will come out in our processing and as they tell their story. I think there's a LOT of power in simply acknowledging that things aren't ideal. "Okay, this is where we are. How can we work with that?" It's not about all or nothing safety, it's about moving towards ultimate safety and creating it in a way that it didn't exist before. If we can't make you fully safe, how do we start taking steps towards safety? It's also being responsible in assignments that are often meant to create safety. For example, not sending a client into a situation with an abuser to set boundaries that will exacerbate the situation. It's also in offering resources if they're in an unsafe, or financially unfeasible place- so maybe one thing won't work, but here's a list of five more we can try. You have OPTIONS.
It's all about acknowledging the reality of the situation and being flexible.
Magic happens when your clients know you'll advocate for them and they can also advocate for themselves.
2) What are some things that could dismiss feelings of safety in therapy?
The number one thing I see get in the way of feeling safe in therapy is miscommunications. It's important for the therapist to be direct and call things out. "I noticed that when (x situation) happened, you shut down. You say nothing's wrong, but I know that isn't true. I need you to know that I don't take this personally and I'd like to walk you through how to solve this problem." Very often the clients will either correct you or bust open with their true response. It happens in moments, little by little, every time they speak up, every time the therapist does and no repercussions happen.
I'd also say setting appropriate expectations, again, from the beginning. If the client expects one thing and another is happening, they can feel slighted, confused, or even relive some of their trauma that brought them in. It's important to be aware of and key into this. And open processing. Every time you process with a client and you don't give them something to fight against, it disarms them and helps them realize they don't always have to brace for a fight. A big part of a therapist's job is modeling- or teaching and showing people how things SHOULD go when all involved are acting in a healthy way. We don't always get it right, but we can still salvage it by modeling repair: "I was having a bad day and I feel I might have snapped. I'm really sorry about that. Can you talk to me about how that made you feel? It's safe to talk about here." Things don't have to go perfectly to be productive. I think that's why this topic is so important. Trauma doesn't happen in a vacuum and it's often cyclical. So, while the ideal may be to help heal a traumatized client in a non-traumatic environment, that's very rarely reality so we have to know how to deal with the messiness of it all.
3) Can you expand on what “while I don’t feel safe I am capable of protecting myself and knowing who to trust” as well as helping them find/create safety" might look like?
Sure, so in your original post, I stated that I don't ever try to get my clients to blindly act as if they are safe, or force them to pretend they are. It's about meeting them where they are. I teach my clients that new narrative of “while I don’t feel safe I am capable of protecting myself and knowing who to trust.” At its core- trauma and anxiety are about a mistrust of others combined with a mistrust of self, which is so paralyzing. There's no right answer! They can't trust themselves to find safe people, they can't trust people to be safe, there's nowhere to turn. The first step is in helping them calm their nervous system. Panic gets in the way. If they can stay calm and in charge and not let the emotions drive, things change. So I ALWAYS start with body work. From there, we examine where these messages came from and in noticing when they come up again. It's in about helping the client build competency- maybe they didn't always have the skills, but we're going to teach them those skills so that the pattern changes.
When you're abused you're dismissed, you're taught that your viewpoint is wrong, and this is driven into your head. That soundtrack is valuable, it keeps you small so you're ultimately less of a target, but then you have to realize that you can take up space again once you're safe. It's all about helping the client realize these things.
Catherine McConnell, MA, CFT, LPC provides psychotherapy services in Texas
4) How can people find more about your work?
I'm creating new content all the time, but for now I have a website (with a blog!) at www.catherinemcounseling.com. People have the option to subscribe if they want to be updated. I'm also running a PTSD facebook page. It's brand new so it's a little inactive, but I'm hoping to grow it! PTSD Information Source
