safety and stabilization

Due to the potential moral injury Cain has suffered, the therapeutic process begins with the stabilization phase of trauma-informed CBT and the grounding practices of MBSR (Courtois & Ford, 2016; Kabat-Zinn, 1990). Before insight can occur, he must experience bodily safety and relational containment. The therapeutic aim is to create physiological and interpersonal safety that allows exploration of previously dissociated material. Four goals emerge in this first stage of the therapeutic process:

1. Formation of a secure therapeutic alliance (Bowlby, 1988)
2. Properly orient Cain to the therapeutic process
3. Grounding practice that down-regulates sympathetic arousal (Kabat-Zinn, 1990)
4. Evaluation of interpersonal dynamics (Karpman, 1968)

foundation

Without a working therapeutic relationship, there’s no chance of transformation. Patients are more likely to form a therapeutic bond with a therapist who embodies a non-judgmental, warm, and compassionate personality, a style that lends to what Carl Rogers refers to as unconditional positive regard (Rogers, 1957). In short, a cohesive ‘us’ working on a specific goal is innately transformative (Bion, 1962; Ogden, 2004).

Providing a sacred space where the patient’s psyche can unfold and develop is quite challenging. Psychotherapists are people, too, meaning they can often be harsh and judgmental. Imagine a patient presents with PTSD complicated by moral injury, like Cain. This man has hurt innocent people. As a result, he suffers occasional panic attacks, depressive episodes, and bouts of rage. If the therapist thinks, ‘You hurt innocent people? You’re a terrible person!’, this unconsciously creates a barrier between the two and stifles the therapeutic process of transformation, even when the judgment is never spoken (Hayes et al., 2011; Bion, 1962; Ogden, 2004).

There’s no will to understand or empathize with the patient when the therapist is afraid or repulsed by them.

Unconditional positive regard for the patient, no matter what they’ve done, is more of a personality characteristic of the psychotherapist than a skill developed in training (Rogers, 1957; Kolden et al., 2011). Interpersonally antagonistic personalities are more suited for work with machines and need to be screened out during training so that they stay far away from delving into the work of healing human suffering. Harm has befallen many prospective patients seeking safety in a space assumed to be sacred.

Many patients have presented having already been in therapy with another provider. They’ve quit, gone months without care, and inevitably come back saying, “My last therapist seemed judgmental”. Upon further investigation, it turns out to be just one slip of the tongue, like “Oh no! You hurt innocent people!?” One instance of judgment, spoken or thought, is enough for the patient to drop out. The reality is that in some cases, not only do they drop out, but they never return to therapy again. Death by suicide is a real possibility in these cases.

Psychotherapists must practice the art of non-judgment. How we view people says something about us. For instance, a therapist who is shocked by Cain’s disclosure hasn’t worked through that type of material before and may rush to judgment and say something like, “that’s terrible!”. In the therapist’s defense, she hasn’t faced this before and therefore lacks the understanding necessary to remain judgment-free.

If the therapist takes the time to process traumatic material, it will allow for a more objective evaluation of patients’ perspectives in the first stage of the therapeutic process (Rogers, 1957; Norcross & Lambert, 2019). A novice therapist may lack that time in the middle of dialogue. It’s recommended they consult with a supervisor or mentor clinician for emotional grounding to mitigate vicarious trauma and sense-making of the material to gain the proper objective understanding of this nuance of the human condition.

Because the therapist is likely to have some distortions of their own, it’s imperative they have a looking glass clear of bias—free of judgment. If the therapist isn’t seeing clearly, unconditional positive regard is diminished, and the patient won’t experience the transformation they’re seeking. 

In his own mind, Cain has done some “terrible” things. He’s hurt innocent people and believes himself to be a “terrible” person. Non-judgment is the basis of objective truth. It allows the psychotherapist to openly and authentically engage in dialogue with the patient in an effort to understand how his perspectives and behaviors developed. Moreover, the therapist’s genuine interest in the patient’s suffering is not complicated by biased condemnation, and tForhe door to compassion and healing remains open.