How we integrate or make sense of our experiences have a lot to do with how they affect us. That's just common sense. However, the drive within psychology towards a research and evidence based practice standards has led to a move away from seeking the consensus of practicing professionals in the field on the formation of theory. A theory informed practice has been the standard for many years. Experts construct a theory based on their professional knowledge, including research. The theory is then tested based on the defined concrete references of the theory, called operational definitions. This is a very common approach to theory construction. For example, testing the theory that the planets orbit the sun, one mathematically works out where each planet should be at some set time in the future based on the theory. When they are found there, that provides one study supporting the criterian validity of the theory that the the planets orbit the sun.

The problem is that psychological constructs are notoriously defined differently by different researchers, and there is little consensus on a grand theory that attempts to explain human behavior. Instead there are a number of theories that have been developed that accounts for behavior based on the thoughts that occur before the behaviors. Research has shown that behavior can change when thoughts about that behavior change. This has been replicated many times. Cognitive behavior therapy is the model in the psychology that enjoys the largest following. But this theory does not explain all or even most behavior, nor does in fit with some of the more common beliefs and assumptions about human behavior.

If changing one's thinking were all that was necessary to change behavior, then more people would be successful with New Year's resolutions. Most people will tell you of their dismal success breaking old habits in the New Year. Throughout 2007, one study tracked over 3000 people attempting to achieve a range of resolutions, including losing weight, visiting the gym, quitting smoking, and drinking less. At the start of the study, 52% of participants were confident of success. One year later, only 12% actually achieved their goal.

Another problem with Cognitive Behavior Theory (CBT) is that it assumes that emotions are just an another form of behavior caused by thoughts. In some cases this may be true. In generally healthy people, emotional issues may well respond to changes in thoughts. But it's clear that Post Traumatic Stress Disorder (PTSD) is largely an emotional disorder, where manifestations have incomplete connections to thoughts. CBT is not the treatment of choice. Some form of exposure therapy is widely used to essentially break the pattern of emotionally driven habitual behavior or extinguish the conditioned emotional responses to thoughts, feelings and external stimulation associated with the trauma. If you experience that memory and it's emotions in a safe setting and recognize that your fears were not realized, then the memory is changed with the addition of this new information. This sort of change is incremental. Such learning may need to be repeated several times the intensity of the emotion subsides to acceptable levels.

Other clinicians see a more profound version of PTSD in combat veterans.

Throughout history, warriors have been confronted with moral and ethical challenges and modern unconventional and guerilla wars amplify these challenges. Potentially morally injurious events, such as perpetrating, failing to prevent, or bearing witness to acts that transgress deeply held moral beliefs and expectations may be deleterious in the long-term, emotionally,

Image by Getty Images via @daylife

psychologically, behaviorally, spiritually, and socially (what we label as moral injury). Although there has been some research on the consequences of unnecessary acts of violence in war zones, the lasting impact of morally injurious experience in war remains chiefly unaddressed. To stimulate a critical examination of moral injury, we review the available literature, define terms, and offer a working conceptual framework and a set of intervention strategies designed to repair moral injury. (Litz et al., 2009)

Georgetown University ethics professor Nancy Sherman heard stories of moral trauma when she interviewed veterans of Iraq, Afghanistan, Vietnam and World War II for her 2010 book, The Untold War. "It might be where you felt you should have been able to do more for your buddies, but you couldn't, or because you simply survived," she says.

"Regret," she writes, "doesn't begin to capture what the soldiers I talked with feel. It doesn't capture the despair or depth of the feeling -- the awful weight of self-indictment and the need to make moral repair in order to be allowed back into the community in which he feels he has somehow jeopardized his standing." (Silver, 2011)

This is not a new idea, but rather repackaging of a well documented feature of all trauma, and not just trauma related to combat. Themes of shame and guilt pervade the PTSD literature, often referred to as complicating factors.

Studies suggest that those who interpret a traumatic experience as intensely negative are more at risk for posttraumatic distress and disorder than those who view the event as less traumatic. Specifically, a woman's reaction at the time of her victimization is likely to be an important predictor of her later psychological state. (Briere & Jordan, 2004)

Certainly conceiving of a victim's behavior during a traumatic event as transgressions of deeply held moral beliefs and expectations would qualify as a particularly negative interpretation of the event and thus predict a more difficult recovery. She is also more likely to develop a shame-based view of herself based on the conclusion that she has demonstrated a moral defect reflected in her behavior. In my clinical work, I've seen this phenomena in traumatization caused by crime victimization, particularly rape, in natural disasters, such as hurricaine Katrina and the Northridge earthquake in Oakland, Ca, as well as combat trauma from Iraq, Afghanistan and Vietnam. The complicating factor of shameful beliefs about personal responsibility when others are injured is a prominent feature in people struggling with a difficult recovery.

This new conceptualization of moral injury may come in a useful form, one that is easily understood by the client and destigmatizing in the sense that a "mental health" problem is consistent with cultural norms. In addition, the authors further the theory of PTSD and its notorious resistance to treatment. The shame of a moral injury leads the sufferer to withdraw from social contact even with close confidants, under the assumption that if she doesn't hide their shameful behavior, others will know and find her disgusting and worthy of rejection. This prevents the natural healing process of sharing and reexperiencing the trauma with the support of a loved one. The expression of love and acceptance despite their shameful behavior becomes part of the emotional memory and gradually attenuates the shame as well as the intrusive memories, nightmares and flashbacks. The authors note that self esteem has been found to mediate between belief that the world is just and in the willingness to self forgive Therefore, self-esteem may be an protective factor from moral injury. The authors also note that PTSD as well as moral injury involve healthy feelings. The affliction of a moral injury is in part a believe that the sufferer is not worthy of self-forgiveness. (Litz et al., 2009)

Litz et al., (2009) outlines a model they call a "modified CBT" approach. They describe eight components: 1. A strong working alliance. 2. Educating about the concept of moral injury and preparing a plan for change. 3. a "hot-cognitive" exposure based processing or emotion focused self-disclosure. 4. A thorough examination of the implications of this experience on the sufferers concept of self and other cognitive schemas. 5. An imaginal dialogue with a benevolent moral authority (such as a grandparent or pastor) about the target behavior and implications for the future. 6. Fostering self-forgiveness and reconnection to the community. 7. An assessment of goals and values moving forward.

I've found it particularly effective to treat PTSD complicated by shame in a group setting, where the many components often become a natural process of the group's cohesion and mutual support. When other group members who suffer from post trauma symptoms share their story of how they believed they had personal responsibility that resulted in another's injury, it's much easier for the sufferer to see other's over reactions and offer support and validation. This helps them recognize their own exaggerated self-blame and begin the process of self-forgiveness, a kind of "opposite action" treatment.

References

• Briere, J. (2002). Treating adult survivors of severe childhood abuse and neglect: Further development of an integrative model. In L. Berliner, J. Briere, C. T. Hendrix, T. Reid, & C. Jenny (Eds.), The APSAC handbook on child maltreatment; 2nd Edition., Briere (2002) (pp. 1-26). Newbury Park; CA: Sage Publications.
• Briere, J., & Jordan, C. E. (2004). Violence against women: Outcome complexity and implications. Journal Of Interpersonal Violence, 199(11), 1252-1276.
• Litz, B., Stein, N., Delaney, E., Lebowitz, L., Nash, W., Silva, C., & Maguen, S. (2009). Moral injury and moral repair in war veterans: A preliminary model and intervention strategy Clinical Psychology Review, 29 (8), 695-706 DOI: 10.1016/j.cpr.2009.07.003
• Silver, D. (2011, September 3). Beyond PTSD: Soldiers Have Injured Souls. Truthout. Retrieved from http://www.truth-out.org/beyond-ptsd-soldiers-have-injured-souls/1315066215

It's been standard practice in Cognitive-Behavioral therapy to teach clients that our thoughts trigger our emotions. Thus with training and practice a client can learn to change feelings by changing thoughts. While that is generally true, what CBT specialists sometimes miss is that some feelings actually control our thinking, often in ways that are beyond our awareness.

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I really enjoy reading the blog Kellevision.com. She says it like it is and seldom misses the point of what she's writing about. She identifies a problem in programming for homelessness and proposes a set of concepts to help clarify the situation.

"Many of the "barriers" faced by the chronically homeless are not external. They are self-inflicted. Repeatedly failing to pay one's utility bills is not a barrier. It is a behavior. Repeatedly getting into relationships with drug addicts and being evicted because you have allowed your new girlfriend to turn your affordable housing into a crack house is not a barrier. It is a behavior. Choosing to pay your boyfriend's bail instead of the rent is not a barrier, it is a behavior. Consistently refusing to hold down steady employment and being evicted for not being able to pay the rent is not a barrier, it is a behavior.

[..]Lastly, how we label the problem determines how we approach solving it. True social barriers need to be addressed by social services. Better programs need to be designed to specifically address the needs of the mentally ill population. Programs designed to assist the medically disabled need to be accessed. But behaviors require a clinical intervention - therapy. Clients who demonstrate patterns of behavior which result in repeated instances of homelessness need counseling, not social services. The problem is not a social problem. It is an individual problem which requires an individual intervention."

I think it's much more complicated than that. Our world has always had an underclass, a group of individuals who have been largely invisible in the US except during the Depression. These people largely function outside the visible society and economy. They share housing with family and friends, squat in abandoned buildings, and sometimes live under bridges. They live off their housemates or family, work for temp job agencies, borrow, steal, deal drugs, and even engage in formal criminal enterprise. Given our recent policies that have reversed the tax-based redistribution of wealth since FDR, the stagnant wages, disappearing jobs, and ever increasing cost of living, that underclass has become so large it is again visible.

They are chronically under or unemployment and are not collecting Social Security, either because they don't qualify, try though they may to apply, or they haven't the where-with-all to get themselves qualified. This chronic underclass is best described as a sub-culture. They are structurally built into the economy. "Full employment" doesn't include them. Because they have given up on finding work, they no longer register with unemployment offices and so are not counted among the unemployed. Those who are chronically homeless are a sub-group of this sub-culture, and probably represents some of its most dysfunctional members.

By describing the chronically homeless, Kellevision describes most of the common attributes of this subculture.

"For the majority of the [chronically] homeless population, homelessness is a lifestyle, not an event.

[..]My purpose here is not to blame the victim, but to talk openly about the severe dysfunction I see in chronically homeless families. Unless we identify the true problem, we will not be able to form a lucid solution. Homeless families typically do not function well on any level. Children are frequently truant from school and display numerous behavior and developmental problems. Dorm rules are constantly broken and there is constant turmoil between the families on the dorm. Relationships are fleeting, intense and severely dysfunctional including domestic violence, substance abuse and exploitative. Interactions with other people are inappropriate or dysfunctional. Most homeless families have burnt all their bridges with every social service agency and with their own families because of their severe dysfunction. Shelter staff often feel like we are running a middle school rather than a homeless shelter. This behavior is what needs to be addressed rather than giving them more money or building more homes.

[..]What are the elements of the homeless mindset? I'm still trying to work this out in my mind, but here are some of them which I see frequently:

• An external locus of control
• the belief that they have no control or responsibility for their choices, actions or behaviors but they are the victim of circumstances
• the belief that the causes for good or bad events in your life are totally outside your control or responsibility
• Sense of entitlement
• the belief that the worlds owes them something and they should be able to collect immediately
• the belief that they should be taken care of by others, by the government or by social service agencies
• the belief that they should be given things they have not earned (i.e. free housing, clothing, food, etc.)
• the belief that others should "help" them (i.e. by paying their unpaid bills or appealing their housing denial)
• Impulsivity
• Poor boundaries
• Emotional immaturity
• Need for instant gratification
• Dependency issues
• Predatory/antisocial behaviors
• Pathological relationships

"

Certainly, not every member of what I'll call the "underclass sub-culture" share all of these attributes. Each and every person has a story behind their situation. A careful account of their histories, something they usually reluctantly give, chronicles the development of these problems. It's important to discourage a prejudice developing against a whole group of people who are already stigmatized along with the "welfare mother" of the AFDC era. But we are not going to get to a more complete solution without understanding the problem. I suspect that why there is little commentary on this topic.

Kellevision hits on what I believe to be one of the most common roots of dysfunction, repeated traumas throughout their life.

"A vast majority of our clients seem to have endured some sort of trauma(s) during their childhood which has(have) halted their emotional development. The result is immaturity, impulsivity, dependency, a sense of entitlement (that someone should take care of them rather than being responsible for themselves), an external locus of control (seeing problems as existing outside of themselves and therefore being outside of their control and/or responsibility), immature relationships and emotional lability. These factors result in behavior which appears erratic and irresponsible."

"Arrested development" is what Kellevision calls it. Indeed, this problem is pervasive and most often multi-generational. There are most often one or more of the following in the family history:

• lifelong repeated exposure to trauma:
  
  
  
  • child abuse and neglect
  
  
  • incest
  
  
  • domestic assault
  
  
  • gang or drug related violence
  
  
  • repeated exposure as a crime victim including assault, rape, and drive by shootings
  
  
  • inconsistent parenting ranging from abusive to no supervision
  
  
  • one or more family member who was murdered
  
  
  
  
• poor performance/attendance at school


• high school drop-out


• parenthood started by mid-teens


• by their twenties, they have several kids with mostly different partners


• sporadic work history and chronic unemployment


• efforts to qualify for Social Security


• family members relying on other families income, so no family member is able to break the pattern of poverty


• chemical abuse


• drug dealing to support a habit


• mental illness


• parents, spouses, brothers, sisters in prison


• criminal activity as income


• crime as a family enterprise

Persons who are members of the underclass see dysfunction as normal. They've never known any different. Many think this is how everyone lives. While they may dream of a good job, they appear to not have the self-discipline to keep a good job. Many of this group might be diagnosed with an anti-social personality DO. Personally, I think this diagnosis is misleading at best. A person earns this diagnosis if their history includes sufficient "anti-social" behavior. This doesn't account for family cultures that teach a confusing mix of conventional and anti-social values. Thus we have neighborhoods that have no constructive relationships with police, believe that justice is against them and label anyone reporting a crime as an informant and not to be trusted. This of course contributes to the chaos in the neighborhood.

In my experience people who get diagnosed anti-social are the ones the clinician don't trust or believe. The whole underclass culture tries to keep their business to themselves. Lying to protect one's family's reputation is encouraged. I suspect while there may be a few classic psychopaths out there, most of those folks who populate our jails are drug abusing, impulsive, underclass members with shut down emotional systems due to repeated chaos and trauma. These folks won't tell you the truth unless they are desperate and already feel they are the lowest of the low. Their judgment is so impaired that they see fear as a weakness they must squelch out. Danger in their world is everywhere and it must be faced, not avoided.

I have worked with some persons of the underclass who have a clinical presentation of PTSD after many years of participation in gang violence. They know what conventional values are, but they also know what is the law of streets. They are scared and tired of living a nightmare, and want a stable peaceful life but are tortured about what they've seen and what they've done to others over the years. Just seeing a gun sets off flashbacks. They describe their younger years as being "shut off" emotionally, and "not caring" about anyone or anything but money. But now in my office, they are presenting a mostly full range of emotion and a guilty conscience that suggests conventional values. Has their impulsive, "immature brain", associated with anti-social acts, matured into a more conventional pattern? Or is it more accurate to describe them as a product of an anti-social sub-culture? I suspect the latter is more accurate.

Returning to the homeless and Kellevision, she notes the major problem with relationships is homeless people's "picker is broken".

"For every person in a homeless shelter with dependency issues we seem to have an predator waiting for them. Half the population seems to be working or receiving some form of assistance and the other half seem to be trying to hook up with them to take advantage of that income....

It is important to realize that single parents contribute to the problem of picking the wrong partner with their own pathology. The single mothers in the family dorm are not simply victims of the men they pick out. There seems to be a predominant attitude of these women that the man should "take care of them". They believe it is just a matter of picking out the right one. The first problem is that their "picker" is broken. They do not pick out a good one. They usually pick out one of the predators roaming the alley behind the shelter. The second problem is that you cannot sit at home expecting to be taken care of in our modern economy. That might have worked in the 1950's, even in the 1970's, but June Cleaver is no more. The modern American household takes two paychecks. Two full-time paychecks. The third problem presents it self when the man expects to be supported by the woman. Even if the woman is working full-time and picks out a man who wants to live off of her, women traditionally earn much lower wages than men. So the family's financial stability is even more shaky.

This predatory - dependent dyad seems to play out in most of their relationships and I wonder if it is not the source of their alienation from their families of origin. A person who constantly expects to be taken care of can be quite tiring. By contrast, a person who is constantly preying on others also becomes quite tiring. "

Having grown up in a chaotic home and living a chaotic lifestyle, repeated trauma has numbed their emotions to the point that they are unable to make proper judgments about who is worthy of trust. The predator-prey dyad began in their family of origin where parents exploited the children when they were young, and when the children grow up, they exploit their vulnerable elderly parents. Recently, in my therapy group, one male member admonished a older woman for setting limits with her adult children because they were tacitly supporting her grandchildren for default on a loan she'd co-signed. He felt family was entitled to lean on, effectively use, each other.

"Mental illness is often cited as a factor in homelessness. A significant number of homeless clients suffer from debilitating mental illnesses and many researchers sight the high numbers of mental illness in the population. However, each researcher seems to define it in their own way. Some include only the big three Axis I diagnoses (Schizophrenia, Bipolar I and Major Depression). Others include substance abuse (since it is an Axis I diagnosis in the DSM IV) which dramatically inflates the numbers of the "mentally ill". Others include Axis II personality disorders, but only some of them, usually Antisocial Personality Disorder. Still others include Post Traumatic Stress Disorder. In my experience, mental illness is a factor in about 10-20% of our homelessness clients and it is a serious problem. However, it does not explain the other 80%. These 80% use an unusually high percentage of services and monies devoted to the homeless and they are repeat customers. "

Here I have to disagree with Kellevision. Everyone I've counseled with substance abuse were running from their feelings about themselves and/or their past. I have found Bipolar DO in significant numbers behind petty criminal activity, gambling addiction, alcoholism, sexual addiction, exotic dancing and prostitution. I participated in a local county survey that identified their most expensive clients. The general profile was bipolar chemically abusive who revolved in and out of the hospital, placements and jail. Personality disorders are mental illness. While many may think the rest of the world is the problem and are not willing to take responsibility, many others are desperate for relief from a horribly chaotic and often traumatic life.

"There is a very high incidence of traumatic histories in the homeless community, even before they became homeless, usually during childhood. I believe that a majority of the substance abuse problem in this population is an effort to treat trauma symptoms. However, this can be said of other populations as well, including the substance abuse community. Most trauma survivors manage to maintain housing despite their trauma symptoms. Though trauma symptoms may play a factor in homelessness, I do not believe they are the sole cause. "

Sole cause, no, it's the multi-generational underclass sub-culture with it's accompanied fractured families, drug abuse, trauma, predator/prey cycle, and chaotic lifestyles. Trauma comes in forms that are not readily identified. Chaotic events in close proximity in time give the victim the impression they have no control of their fate and so they scramble for every edge in the moment, and anxiously await for the next disaster to strike. Those in the underclass go way out of their way to withhold their histories of trauma and chaos, insisting that they can handle their own problems, and it's none of anyone's business. Or is this simply the accepted cultural method to deal with the shame of their past?

"Most homeless clients do not have family support systems. If they did, the family would take them in and they would not be homeless. Many homeless clients come from families who are themselves very nomadic and teetering on homelessness. Some come from families rife with substance abuse, sexual abuse or domestic violence. Others have been rejected by their families for various reasons. These reasons often involve their dependent and/or dysfunctional behaviors. "

Underclass families exploit each other until the resources are gone, or the member with resources cut off the leech. Once the underclass has used up their family resources, they become at risk for homelessness. Many have family who died young living violent or drug infested lifestyles, or who are in prison. By this time, they've burned out most of their friends as well. All they can do and meet new vulnerable people and continue a new predictor/prey dynamic.

So what solutions are there for healing the cultural divide? The problem is mostly economic. The underclass lacks a realistic chance for escaping their plight. Oh, sure a few make it, usually through advanced education. But many will hit a ceiling in achievement when they rely too heavily on "temporary feel good" behavior that provides relief from stress, but self-destructively complicates their lives and increases the chances they will fall out of their newly found middle-class status.

The middle-class in America is shrinking, many of the hard working blue collar workers are falling into the underclass from where with a floundering economy, escape will be difficult. Jobs programs, affordable housing, and counseling are sorely needed but remains largely unfunded. What infrastructure is present is actually shrinking with government tax dollars.

Too often the only role models for success are the gang members, drug dealers or pimps who drive fancy cars and flash wads of money. Too many get lost in this dream turn nightmare. But my experiences working with recovering gang members is that many are retrievable when they get desperate enough to escape with the right kind of treatment and patience with their guarded presentations. I work in a Partial Hospital Program (PHP) at an inner city public hospital that is designed to intervene with persons with personality disorders. It's largely based on the Crisis Intervention model that relies on the desperation of the client to inspire commitment, insight and behavior change in therapy. The PHP format is ideal for persons who are suffering from acute exacerbation of substance abuse, PTSD or personality disorder. I call it "mental health boot camp". We have a satisfaction rate of over 90%.

Kellevision lists a number of problems within the system.

"In my humble opinion, our current social services system and is a major factor contributing to the homeless mindset. This is a complicated element to explain. But I think it is important to make an attempt.

I see two major problems with the social services system: 1) the system itself - how benefits are applied and eligibility determined and 2) the people working within the system - the mindset of caseworkers and social workers working with the homeless population. "

• The social services system seems to be designed to punish attempts by the poor to achieve independence. Assistance programs penalize people for working "too much" by cutting off benefits when assets accrue. These systems often reinforce irresponsibility and impulsivity while punishing people who try to work and plan ahead.
• Many social services programs seem to "teach" clients to wait until the last minute then create a dramatic "emergency" in order to get help. This fosters the emotionally immature and histrionic displays in emergency rooms.
• Our current welfare system does not allow exchanging work for benefits. Benefits are given away free.
• Caseworkers and social workers have a bad habit of doing things for clients, rather than expecting the client to do it or teaching them how.
• So what have clients learned so far?
  • Don't work too much.
  • Don't plan ahead.
  • Expect someone else to provide you with what you need.
  • Don't take responsibility. Someone else will fix it for you.

The welfare system is complex, cumbersome, and difficult to change into a working entity. The major problem is that it is designed not to serve the poor, but to mollify the political needs of the tax payer. That makes it inherently punitive. As we know from behavioral science, punishment doesn't change behavior. I believe it in fact feeds the cycle similar to the one Kellevision describes above. As long as we put political considerations ahead of evidence-based methods, we'll have a broken system.

Kellevision proposes ideas that I think have significant merit.

"I think counseling should be provided liberally. Teach people how to fish. Teach them how their maladaptive behaviors impair their ability to function. Stop rewarding bad behavior. Stop giving away money. Stop cleaning up their messes for them. Stop giving away free stuff.

Once homeless clients are assigned jobs, they would be provided with counseling to address the behavior problems that interfered with their ability to maintain employment. If they failed to come to work due to a poor work ethic, substance abuse problems, domestic violence or other relationship issues, etc. instead of getting fired - again - and having another black mark on their work history, they would be required to participate in counseling or group work to address it. "

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Recently, I exchanged messages with Michele Rosenthal, author of the blog, Parasites of the Mind. She asked me a very good question, one that is so much a part of my everyday work, a good long contemplation was needed just to tease out a good answer.

"Speaking of inspiring, how do you inspire a client to believe in what he/she is doing? It's so difficult to believe in anything when PTSD has settled its big black cloud on your head.

Any general rules of the game for (self) empowering belief?"

Another therapist, Mary Redoutey, joined our discussion and attempted to answer this question. She took the conventional route.

"All therapy in essence is self empowered therapy.... The therapist is the partner in the process. I can sit in the chair in my office, can make suggestions, can teach, can do anything as much as I want... and nothing different will happen unless of course the client is present, listens somewhat attentively, suspends negativity long enough to experience a shift in feeling state and/or thoughts or actions.... And the work in the session does not transfer into the client's life unless the client chooses to make the necessary changes. "

Essentially, Mary says that therapists don't change people, people can only change themselves. I have commented on a release for a new book that made this point as well. While it is true that what a client brings to therapy may account for much of the effectiveness of therapy, I don't think this is the core of Michelle's question. As I understand her question, she wants to know what the therapist brings to the therapy room.

My first attempt at replying was rooted in my daily routine. I'm always helping people understand how their past experience impinges on their current symptoms.

"Consider what happens between mother and child. A child develops their self-concept initially based on how they are treated by their mother. In therapy, the therapist communicates his belief in the client. And if the connection already exists, a seed is planted. But as an adult, only the client can nurture the seed to germination and growth. The therapist can only teach them how."

Generally, when I take this tact, which is common with the childhood trauma survivors I see, I am helping them see the importance of exploring their childhood history and their relationships with their caregivers as a way to understand the origins of their symptoms. This is a much more specific answer that still only partly answers Michelle's question.

I think Michelle wants to know what is the therapists role in motivating a client in each and every step through therapy. In other words, what is the client getting from paid expert advice they can't get from a book? From Michelle's point of view, perceptions of her options are clouded by the rollercoaster existence that accompanies PTSD.

There has been extensive research on this topic. Most recently, much of this research has taken on a ideological fervor endorsing Cognitive Behavior Therapy (CBT). I've written often about my opinion CBT. Suffice it to say, CBT may be the core methodology in helping a client manage their thoughts and building treatment plans, but there is much more to behavior change than changing thoughts. One of CBT's central assumptions is patently false. Not all feelings are produced by or changable by thoughts. Much of our earliest learning occurs before thoughts begin to play a major role in our learning around the age of 8.

Patterson (1989) identified common specific factors recognized by virtually all schools of psychotherapy. He included therapist acceptance, permissiveness, warmth, respect, nonjudgmentalism, honesty, genuineness, and empathy or empathic understanding. Three of these, warmth, empathy, and genuineness have considerable research backing. In a previous article, Patterson (1984) points out:

"There are few things in the field of psychology for which the evidence is so strong. The evidence for the necessity, if not the sufficiency, of the therapist conditions of accurate empathy, respect, or warmth, and therapeutic genuineness in incontrovertible.... The fact that specific change occurs in a therapeutic relationship without the addition of so-called specific techniques, such as interpretation, suggestion, instruction, etc., is also evidence of the sufficiency of the relationship by itself. "

More recent research has found the competence of the therapist is critical. Verhofstadt et al. 2008, in their article about the value of emotional similarity and empathic accuracy in support giving with couples. They cite:

"...mounting evidence that unskilled support can be ineffective or even harmful to the support recipient.... In summary, whereas matching the partner's emotion during a support-seeking interaction may provide a sufficient basis for understanding the partner's current affective state(s) and responding with appropriate emotional support and consolation, understanding the partner's specific thoughts and feelings during a support-seeking interaction may provide a sufficient basis for understanding what kind(s) of help the partner desires and how to provide such help in an acceptable way."

Successful therapists must be able to adapt to their clients' emotional uniqueness and to accurately perceive their thoughts and feelings to provide appropriate support in an acceptable way. Perhaps even more important, therapists must be perceptive and adaptive enough to understand the clients complaint that brought them to therapy and the nature of their quandary beyond the clients' own understanding, or the underlying problems. And having discovered what must be done, therapists must be able to provide the clients insight into their dilemma, provide a rationale for a course of action, and persuade their clients to make changes they are unlikely to find easy or achieve without significant discomfort. Initially, clients are often unable to understand the significance of their problems or nature and potential benefit of the required changes. If they did they wouldn't need therapy!

There is only one experience that I find cuts through virtually any dark cloud, and that is the touch of human empathy. When people who are overwhelmed by pain suddenly find someone who seems to understand how they feel, they no longer feel alone and abandoned by the world. A skilled therapist can provide more than the usual kind of empathy. After years of exploring the human condition, the therapist reaches within the client's experience that at least begins to provide some meaning to explain and place in context her experience.

Preston and de Waal (2002) describes the nature of human interaction as involving an exchange of complementary emotional and thought messages. These shared representations allow people to adjust their responses based on the communicated states of others suited to relieve each others' distress. (Cited in Gruhn et al., 2008)

Grillion et al. (2008) describe the emotional exchange between client and therapist and the unique skills required of the therapist.

"When the context becomes safe enough for the client to lower his or her defenses, the alteration of regulatory structures becomes possible. The therapist's own self-regulatory movements reveal his or her inner states to the client. Much like the "good enough mother", the therapist's efforts to regulate his or her own inner states show the client that he or she is in contact with the client. Personal therapy for therapists helps to extend the range of experience that they can draw upon in their work with clients (Schore, 2006, cited in Grillion et al. (2008). According to Amini et al. (1996) the most effective interventions are based on the therapist's awareness of his or her own physical, emotional, and ideational responses to the client's veiled messages.

Accordingly, when the therapist has increasingly expanded self-integration and awareness in regard to his or her state of mind with respect to attachment, then he or she has a larger capacity for assisting clients to achieve integration and awareness. This understanding derives from the primary attachment relationship within the developmental psychobiological perspective in which parents who have secure or "earned" secure states of mind with respect to attachment function in certain ways (including attunement and sensitivity) with their infants that result in attachment security in their children. Therefore, from an attachment point of view, the more secure the therapist is, the greater the likelihood is that he or she can assist clients with achieving greater security (Beebe, 1998, cited in Grillion et al. (2008). Therapist self-awareness broadens "clinical intuition", which is referred to as the art of psychotherapy (Bugental, 1987; Schore, 2006; cited in Grillion et al. (2008). "

Thus the relationship of between therapist and client is perhaps the second most important aspect therapy, right behind client characteristics and motivation. So it is critically important that the client has a good relationship with the therapist. Clients must be willing to shop around to make sure there is a good match. Cooper (2008, quoted in Croft, 2008) makes research based recommendations for finding the right therapist.

"Think about choosing a therapist who can help you build on your strengths - for instance, if you are good at understanding why you do the things you do, a therapist who can help you develop these reflective skills may be more use to you than a therapist who wants to focus mainly on your behaviour or emotions. Ask potential therapists what thoughts they might have on why you are facing the difficulties you are and what they think might help. If these are radically different from your own understandings, it may be more difficult to establish a good working relationship. Ask yourself whether you like your therapist and feel respected by them - the quality of your relationship, early on in therapy, will be one of the best indicators of eventual outcomes, so don't put up with a bad relationship. Remember that probably the best predictor of the outcomes of therapy will be the extent to which you actively involve yourself in the process."

References

Croft, Alison. (2008, October 17). Clients, Not Practitioners, Make Therapy Work. Press release by the British Association For Counselling & Psychotherapy on a new book Cooper, Mick (2008). Essential Research Findings in Counselling and Psychotherapy: The Facts are Friendly. In Medical News Today. Retrieved May 1, 2009, from http://www.medicalnewstoday.com/articles/125815.php.

Grillon, C., Pine, D., Lissek, S., Rabin, S., & Vythilingam, M. (2009). Increased Anxiety During Anticipation of Unpredictable Aversive Stimuli in Posttraumatic Stress Disorder but not in Generalized Anxiety Disorder Biological Psychiatry DOI: 10.1016/j.biopsych.2008.12.028

Grühn, D., Rebucal, K., Diehl, M., Lumley, M., & Labouvie-Vief, G. (2008). Empathy across the adult lifespan: Longitudinal and experience-sampling findings. Emotion, 8 (6), 753-765 DOI: 10.1037/a0014123

Patterson, C. H. (1984). Empathy Warmth And Genuiness In Psychotherapy: A Review Of Reviews. Psychotherapy, 21, 431-438

Patterson, C. H. (1986). Foundations For A Systematic Eclectic Psychotherapy. Psychotherapy, 29, 427-435

Verhofstadt, L., Buysse, A., Ickes, W., Davis, M., & Devoldre, I. (2008). Support provision in marriage: The role of emotional similarity and empathic accuracy. Emotion, 8 (6), 792-802 DOI: 10.1037/a0013976

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Trauma recovery is a major part of what psychotherapists do. There is much made about the traumatic effects of major disasters like the Typhoon in Myanmar, the Tsunami in the Indian Ocean, Hurricane Katrina, the war in Iraq, and the tragic events of 9/11. There have been many reports about the walking psychologically wounded from these events. There has been considerable effort to training emergency responders in "Psychological First Aid".

Does everyone who was traumatized need therapy? The answer is a resounding "No". There is research to show that many if not most people adjust to trauma as a matter of course. It's as if their own built in coping mechanisms are sufficient for recovery. So, unless there are symptoms of "Acute Stress Disorder" treatment is not indicated and could do more harm than good.

PsyBlog

"These techniques are in line with the 'hydraulic theory' of the emotions - a popularly held view of how the emotions work. In this view, people's emotions work in the same way as a pressure cooker. Emotions build up inside until the mind can no longer contain the pressure. Then steam is 'let off', releasing the pressure inside and improving the mood.

[..]People who choose not to let off steam in this way are popularly seen as being in denial, and this denial is often seen as pathological. Dr Seery's study extends these criticisms to attack the broader idea that talking about a traumatic event soon after it has occurred is usually beneficial. Mounting evidence suggests that those who do not talk about a traumatic event are simply more resilient, rather than being in a state of pathological denial."