"That’s where psychotherapy can be helpful. It can help people deal with the world of people when people have been the very thing that have harmed you."
Robert T. Muller, Ph.D. trained at Harvard, was on faculty at the University of Massachusetts, and is currently at York University in Toronto. Dr. Muller is a Fellow of the International Society for the Study of Trauma & Dissociation (ISSTD) for his work on trauma treatment. His recently-released "Trauma & the Struggle to Open Up" was awarded the 2019 ISSTD award for year's best written work on trauma. And his award-winning bestseller, "Trauma & the Avoidant Client" has been translated widely. As lead investigator on several multi-site programs to treat interpersonal trauma, Dr. Muller has lectured internationally (Australia, UK, Europe, USA). He founded an online magazine, "The Trauma & Mental Health Report," that is now visited by over 100,000 readers a year. With over 25 years in the field, he practices in Toronto.
SWY: Can you briefly describe your experience working with those who have experienced childhood trauma?
RTM: I work with adults, teenagers, children, sometimes also couples, so a number of different people where one or more of the people in the family have experienced childhood trauma. When I do individual work, it’s typically with adults who have experienced some form of childhood trauma. By trauma, most of the time, I’m referring to interpersonal trauma. Of course, there are significant traumas that happen through natural disasters and that sort of thing, but most of the traumas that people experience, at least in North America, are sadly traumas that have occurred in the home; domestic violence, experiencing abuse as children. One of the traumas that I feel has not gotten enough attention as it should is emotional abuse. It turns out, there are a number of research studies that show that the consequences of emotional abuse are about as significant as the consequences of physical and sexual abuse. People who have experienced severe feelings of being unwanted and gaslighting (where people are told their experiences don’t count, such as experiencing sexual abuse, telling another person about it, and that person blames them and tells them that experience doesn’t count, you’re lying), that experience is an equally significant trauma as physical or sexual abuse per se. Many of the people that I work with have those kinds of experiences in the past.
SWY: You have written two bestselling books, Trauma and the Avoidant Client: Attachment Based Strategies for Healing, and Trauma and the Struggle to Open Up: From Avoidance to Recovery and Growth. Why do you think your books are important reads for both therapists and clients alike? What insight do you hope your books bring to discussions about trauma recovery?
RTM: There isn’t a lot out there to help clinicians who are working with people who have mixed feelings about talking about their trauma. Trauma and the Avoidant Client refers to people with an avoidant attachment. That means that they avoid vulnerability and relationships; they are uncomfortable admitting that they need help, they try to rely on themselves and cut off relationships, and have a lot of difficulty with intimacy. It turns out there isn’t a lot out there for working with people like that. They’re really challenging in therapy. Part of the reason they are challenging is because many have developed coping strategies like drinking, workaholism, eating disorders, etc.; ways of distracting themselves from their internal pain. Very often, they have strategies to deal with their problems, such as drinking or substance abuse, that sort of thing. The problem is that those coping strategies work well for a short period of time, but in the long run, they really don’t work well at all. Very often, they don’t want to come in for help because they have a way of coping. They say, “Hey I’m dealing with my problems, I know what I’m doing.” And again, they do to some extent, coping strategies are just that, coping strategies. But in the long run, they very often don’t help. Those individuals can be what’s called “help-rejecting.” They’ll have friends or family members who say, “Hey, you’re dealing with your problems through workaholism. What’s going on here? You need help” and they say, “I’m doing okay. I don’t need help.” So, it’s tricky when people say I don’t want help, I don’t need help, but their family member sees their brother or their partner who needs a lot of help. There isn’t a lot out there for people who have an avoidant attachment. That’s why I wrote the first book to help clinicians working with those kinds of clients.
The second book I wrote, Trauma and the Struggle to Open Up, focuses on the psychotherapy relationship and how it can be used to help heal trauma. There is a lot on working with people who have trauma histories and helping them feel safe in their outside lives because so often they don’t feel safe, and there’s really good books out there. But there aren’t a lot of books on helping people navigate the ups and downs of the psychotherapy relationship with trauma survivors. It turns out that when you’ve been abused or neglected, the psychotherapy relationship itself is really quite difficult because just like I talked about in the first book, you’re relying on somebody. And that’s really scary when your trust has been violated for years and years. Relying on a therapist becomes a really scary thing. People who are in psychotherapy do all types of things to deal with the fact that they’re scared of relying on their therapist; they’re scared of trusting the therapist and push the therapist away when they need them the most. So how do you navigate the therapy relationship when the person needs help, is looking for help, but is saying, “I don’t need you,” but they kind of do need you and they have mixed feelings about it all. It’s not that they say they don’t need you and that’s it. They say one thing one day and one thing another day because they have mixed feelings, and again, it’s not to blame them because trust is really hard when you’ve been traumatized. You know you need help, but you’re also really scared of getting that help. So, they’ve got mixed feelings. You could see how that would be complicated for the therapist; how to work with this person in a way that’s respectful, helps them, calls them out on stuff that they do that gets them into trouble. Navigating the ups and downs of the therapy relationship, that’s where I focus my second book.
"It turns out that when you’ve been abused or neglected, the psychotherapy relationship itself is really quite difficult"
SWY: You state in Trauma and the Struggle to Open Up that “The opportunity to share with someone who is nonjudgmental, who takes one’s story seriously, who listens without overreacting, and who can help find new perspectives…Such an opportunity can be life-altering.” Why do you think therapy is particularly helpful for survivors of childhood abuse? How can therapy be a useful intervention in stopping this trauma from being passed from generation to generation?
RTM: Psychotherapy is really helpful because it leads people to question the way they’ve been dealing with things in relationships. To some extent, when you’ve been traumatized, not trusting people can be a very reasonable strategy; it keeps you safe. The problem is, if you want to have a boyfriend or girlfriend, if you want to get married, if you want to have children, if you want to have friends that you can trust, not trusting really gets in the way. Very often, people themselves feel, “What’s wrong with me? Why can’t I move forward in my everyday life?” That’s where psychotherapy can be helpful. It can help people deal with the world of people when people have been the very thing that have harmed you. It has to be a relationship-oriented piece of work with a therapist. For the client, who’s a survivor, it’s hard; they’re taking an emotional risk and saying, “Hey I’ve been hurt before and now I’m going to trust this person.” That’s hard, it’s asking a lot of somebody, but indeed, it’s part of what helps them heal. Taking that emotional risk. It’s a calculated emotional risk – You should interview your therapist before you decide that you’re going to go with this therapist. You should seek a good therapy relationship where you meet with a few different people to make sure that it’s the right fit because if it’s the wrong fit, it could really be awful actually. But when you find a good therapist that works for you, that can be very helpful for people.
SWY: You repeatedly describe the Adult Attachment Interview (AAI) in Trauma and the Struggle to Open Up, and its specific usefulness in understanding survivors of childhood interpersonal trauma. You mention that this interview focuses on early life events and relationships and the way that these experiences shape one’s understanding of attachment, the world of relationships, and the way interpersonal needs are or aren’t met. Why is this interview an important step for therapists to begin with when assessing survivors of childhood abuse? Are there any specific responses therapists should watch out for when working with someone who has experienced trauma at an early age?
RTM: The Adult Attachment Interview is not a technique I developed. It’s a technique that was developed by a psychologist Carol George and her colleague Mary Main in the late 1980s. It’s an older interview technique, and it’s a really good technique for helping get a good sense of how the person talks about their history of relationships in the past, while growing up and in their childhood, and how they now view the world of relationships. There are some tough questions asked in the AAI; questions like were you ever hugged or held as a child, did you ever feel rejected as a child, during times of illness or upset, who did you turn to, were you ever frightened or worried as a child? The technique really encourages the person to talk about their personal life stories and the emotional experiences that revolve around those stories. When you use that in therapy early on as a clinical technique, it opens the client up to the idea that psychotherapy is about us really talking about our personal stories, our narratives. It opens the person up to the idea that therapy isn’t just chit-chatting; it isn’t just venting, it’s really about questions and ideas that are quite personal. That can be hard for people, but it’s useful. Psychotherapy is hard. It’s different than chit-chatting with a friend. If psychotherapy has turned into relatively superficial chit-chatting, that might be nice and feel good, but it’s not ultimately something that will help create change. In psychotherapy, we’re in the “growth and development” business. We’re about helping people grow and change, challenge themselves, and look at their past, how they’ve had certain patterns and how they can do things differently and understand themselves differently so that their lives can actually be better in concrete ways. When done well, it should be hard work. If it’s exhausting, don’t be surprised. It’s hard for clients who’ve been through it. It’s painful. But it should also challenge them to do things differently so that they can improve their lives in the direction they want to go. So, that’s the connection between the AAI and psychotherapy. In my book, I do refer to it and there’s some good books written about the AAI that if you’re a clinician, can help you apply this in your practice.
SWY: Can you describe why ensuring that clients feel safe and validated is so important for trauma therapy? How are these two feelings specifically crucial for survivors of childhood abuse, and what can therapists do to best foster them?
RTM: Validation is central, and safety is the experience a person has when the therapist does a good job at validating. What that means is that you listen carefully as a therapist, you’re patient, you don’t make assumptions. People have complicated feelings around their traumatic events. Sometimes, with some clients who have been physically or sexually abused, you think that they would be mad at their abuser and many are, but in the real world, people are complicated. Sometimes you find people who will defend their abuser. You as a therapist go, “How can this person be defending this person who did terrible things?” You struggle with it as a clinician. The reality is, if you’re really listening to the person, people have mixed feelings. If you’re really going to take validating seriously, what you need to do is validate the host of complex, sometimes opposing feelings that people may have in the real world. Your client may be mad at the person who abused them. The client may also feel guilty and go “Oh gosh, am I being mean to my abuser?”, and you’re thinking as a clinician, “No you’re not being mean! You’re right for being upset.” But the person nevertheless feels guilty, so you may need to validate their feelings of guilt. You may need to validate their feelings of low self-esteem. And again, you wonder “Why should you have low self esteem?” But if you truly listen to the person, you validate, you’re empathic with that. It also means that you listen to their story, you don’t discount their story, and you certainly don’t blame the victim. You don’t say to them all the things they worry about – So many rape survivors struggle with blaming themselves and saying, “Why did I do that? I shouldn’t have done this, I shouldn’t have done that.” You want to really listen to them. Validate their worry. It’s understandable that they’re worried they did the wrong thing, but you might offer some psycho-education and say, “Many survivors blame themselves and you really do need to understand that it was not your fault and that you were put in a position of being victimized by others.” You want to validate the idea that their experience is reasonable. You want to validate the mixture of different feelings they may have. You don’t want to do any gaslighting where you say to somebody, “I discount your experience.” You want to really hear them and listen to the complexity of their story. And that’s easier said than done because as I’ve said, so many survivors have a host of different, sometimes opposing feelings about their abuse. Part of the reason that they have such mixed feelings is that so often, abuse experiences happen with loved ones. The idea of the person lurking in the bushes raping you, yes, that does happen, but much more often, it’s a boyfriend, husband, a female partner, etc. So often, it’s someone they know who abused the person, so the client may really feel guilty about being angry at the person. People have complicated feelings when they’ve been abused and this is certainly true in domestic situations. That’s why validation is really important, and it does build a sense of comfort. When they feel validated, they’re like, “Ah, here’s a person who gets it, who isn’t minimizing my experience.” So, it’s very important in therapy.
"Validation is central, and safety is the experience a person has when the therapist does a good job at validating."
SWY: From your experiences, what would you say is something that is commonly misunderstood about those who have experienced trauma?
RTM: There are many things that are commonly misunderstood, I’ll focus on just a couple. One is, many trauma survivors, especially people who would be said to have complex trauma, they struggle with their emotions because their emotions have been invalidated. They’ve been told to shut up about their personal experiences. They’ve sometimes felt overwhelmed by fear and anxiety in relationship contexts. Many struggle with regulating their emotional experiences. A good number of people who have complex trauma engage in deliberate self-harm. This could be a number of different ways: using substances can be self-harming, staying up late and not getting good sleep, poor self-care, but also things like cutting and eating disorders. Therapists sometimes get nervous about deliberate self-harm. If someone cuts themselves, it could get infected or they could bleed and end up killing themselves. For good reasons, therapists are concerned about self-harm. It’s really important if you’re a therapist or a loved one and you have someone in your life who engages in deliberate self-harm, not to assume that deliberate self-harm is always a suicide attempt. Sometimes when people cut or try to harm themselves, it’s because they’re feeling overwhelmed emotionally, and the harm brings down the emotion a notch so they feel better. Sometimes a clinician working with a client who self-harms needs to relax a bit about the self-harm and help the person find alternate strategies to regulate their emotions. If you can help them as a clinician find a different way to calm the turbulence of the emotion that comes up when they are triggered, if you can help them find alternate ways to calm those feelings, then they don’t have to engage in the deliberate self-harm as much and don’t have to be brought to an emergency room and this and that. It’s an important technique to be aware of if you’re new to working with trauma survivors.
The other thing I want to mention is about understanding trauma survivors in the general population. Many trauma survivors engage in something called dissociation where they cut off their feelings and check out mentally. They think about other things and don’t even realize they’re doing it. They just are elsewhere mentally, in a different state of mind. This can be a helpful skill when you’re overwhelmed in a traumatic situation. Prisoners sometimes do this. They’re being tortured and they dissociate; they go elsewhere mentally. Our minds do this when we have overwhelming feelings. Dissociative identity disorder, which in the past has been called multiple personality disorder, is when people really dissociate so much where they just are completely different at times in their life. This has gotten a terrible representation in popular media as people that are dangerous. The reality is people with DID are no more dangerous than anybody else on the street. The only person people with DID are sometimes dangerous to is themselves. Because they are overwhelmed by their trauma and memories, sometimes they dissociate and that’s when they may engage in the deliberate self-harm stuff. That’s where they may be more dangerous to themselves, but they’re not more dangerous to anyone else in the general public. So that’s something to really be aware of in terms of understanding trauma survivors.
SWY: If you could say one thing to someone who has been victimized by childhood abuse, what would it be?
RTM: The main thing would be to get help. Trauma and its consequences are very treatable. I’m not a big medical model kind of person, and I’m not saying it’s necessarily a medical thing. There are a lot of ways people can feel better. It might be seeing a psychiatrist, it may very well be seeing a psychologist, social worker, psychotherapist, but it may also be getting help in other kinds of ways that are more creative. For example, expressive arts therapy has shown to be very helpful with trauma. Music therapy. Even if you’re not big into seeing a mental health practitioner, there are a lot of ways. The other thing I want to mention is martial arts and yoga. All of these, art therapy, music therapy, martial arts, and yoga, all of those are bodily focused ways of improving creativity. There’s a social element to them as well, a physical, and also an opportunity to get your emotions out in all kinds of way. Some people can get their emotions out by talking about them, and if you can, that’s great, psychotherapy can be really helpful. If you’re going to go for psychotherapy, talk to a trauma-informed therapist. If you have depression because of trauma, a depression expert may not be able to help you with the trauma piece so you might be spinning your wheels. You want to go to someone who is trauma-informed. So, if you have a trauma history and you’re experiencing depression because after all, having a trauma history can be very depressing, see someone who is trauma-informed. A depression specialist, but someone who is trauma-informed. But if talking about your stuff isn’t your bag, that’s okay, then please engage in martial arts. It’s really helpful; I’m serious. Karate, kung fu. Domestic abuse survivors who join some sort of martial arts group find it really helpful. Yoga is also really helpful. Trauma-informed yoga. Any of those that are multi-modal, that engage the body, because so often trauma is in the body. You feel scared, you shut down, you cover yourself up; all of these techniques are ways to connect with your body so that you can start to actually like your body again. So, seek therapy in any of those possible ways.
SWY: What do you think we, as a community, can do better to help survivors of childhood abuse recover and grow from their experiences?
RTM: The biggest problem is that there isn’t enough consciousness on a larger social level of this as a real thing. The #Me Too Movement is fabulous; it’s a great start. It’s only in 1980 that the term PTSD was coined in the medical literature. Again, I’m not a huge lover of a strict medical model for treating trauma, there are lots of things to complain about for sure. But one positive thing about it, is that it helps create language. The term PTSD, before we had that term, what was the alternative for Vietnam Vets in the 1970s? Many of them felt like they were cowards. Many of them felt like they were just losers. There wasn’t good language. Of course, we had terms like shell shock and battle fatigue from World War I and World War II, but those, still, were very judgy kinds of terms. It wasn’t until PTSD in the early 1980s that we had some consciousness and language to say, “Hey, these men and women, these service people, really need help and it’s a medical problem. We can’t judge them. We need to care about them and treat them.” And again, even if you don’t feel treatment is the right thing, at the very least, we need to help them, we need to find ways to get them help. We need good language like that for survivors of domestic violence. The term complex-PTSD has sometimes been used for survivors. Domestic violence is a word, but we need something in the psychiatric literature because psychiatry is very powerful. We need something that is a public acknowledgment that people are survivors of trauma; it’s a real thing. We need to be aware of it. Whether it’s medical or not, my main concern is that these are real people with real problems who truly need help, and the problems are a result of things that happened in their lives. We need a multi-modal way of treating them. One is absolutely consciousness about what’s right and wrong, rules of engagement in domestic situations, and that violence is intolerable under any circumstances. We need legislation that it is illegal to spank children. Why is it legal to spank children in Ontario? Why? How can that be? We need more consciousness around how violence is never okay under any circumstances, for relationships, in marriages, towards children. We need a multi-modal approach to create consciousness that there are individuals who are being traumatized in family situations. Also, we need funding to help give them help. Whether that’s in the form of funding for psychotherapy, or funding where they would get trauma-informed yoga or other interventions that have been shown to be helpful. Those are all the things we need in order to be able to provide the help for people who have been victimized in these domestic situations. Just like we have a consciousness about helping our servicemen and servicewomen who have PTSD. That’s where I would say we need to get to where we’re not yet at.