New therapist, new hope

I woke up on the morning of 15 March 2016, with a first session booked with my new therapist. I was wondering why on earth I was bothering… it seemed all therapists were the same. The thought of spending the rest of my life doing what I had done before was intolerable. I honestly believed that I would be better off dead, and I made a plan for how I would kill myself after the therapy session. The mind plays strange tricks: I decided that I would keep the appointment because I had paid for it. If I hadn't, I doubt I would still be here.

Throughout the session, I was distracted by the conviction that I was going to kill myself afterwards. I had gone past the cry- for-help stage, so I didn't tell my therapist. I was convinced my situation was hopeless. I had been convinced by my IAPT therapist that the only way for me to resolve my issues with work was by exposing myself to it, and yet doing so was re-traumatising for me. It seemed that I was in a no-win situation. My trauma was from being forced to do something I didn't want to do, and so I was also terrified of being hospitalised.

I couldn't progress without therapy, yet if I had therapy, my therapist was just going to re-traumatise me.

Towards the end of our session, with my therapist explaining about keeping me within the window of tolerance, he uttered these words: 'I will not try and force you to do anything you don't want to do'. I was flabbergasted. Here was a therapist who seemed to understand trauma. In the few moments afterwards, I had to reorient myself. I didn't need to kill myself. The relief was overwhelming, it rendered me speechless.

In those few moments, I had gone from despair to hope.

The emails

In between therapy sessions I would email David to get help when I was struggling. Doing so helped to deepen the client-therapist relationship, and this made all the difference to my healing. This email exchange is the topic of my self-published book, Childhood Trauma Recovery: The Email Conversations With My Therapist That Helped Me Overcome Childhood PTSD.

Here, I include several, nonsequential emails, followed by thoughts from myself and David on this form of communication in therapy.  

28 April 2016; 15:18

To: David Pike From: Fran

Subject: New appointment 


Hi David,

I would appreciate another appointment early next week as I am being knocked for six by emotions to do with my mum that I am struggling to process by myself.

Thanks, Fran

28 Apr 2016, 15:48

To: Fran From: David Pike

Subject: New appointment 

Hi Fran,

I know it is difficult to handle such emotions – make sure you have some positive things to be getting on with as you need to employ your imagination productively. Think of 'taming' your imagination so that it learns to serve not dominate you. Just be persistent. Take things one step at a time – do not worry about the future too much unless where you want to go becomes obvious. Otherwise do the boring things that need to be done. A mantra is something to repetitively focus on that will protect you from your own mind; make up a phrase that will counter anything negative that undermines you.

Get in touch again if you need me.   

Many regards,

David Pike

Consultant Clinical & Health Psychologist

28 April 2016; 15:54

To: David Pike From: Fran

Subject: New appointment

Thanks for your support. Part of the emotions were around not being believed/taken seriously, so I am grateful that you haven't dismissed me.

Thanks for the help re a mantra. I have started doing the Loving Kindness Meditation again which I have found helpful before, so I will do that as well.

See you Tuesday, Fran

21 May 2016; 12:11

To: David Pike From: Fran

Subject: New appointment 

Hi David,

Thanks for your help last week. I am feeling more optimistic.

Someone I know posted an article about aphantasia – the inability to visualise – on Facebook, as she also has it. She's a philosophy lecturer. Her mum didn't know she had this until she posted about it. It seems people with aphantasia can't 'hear' music or similar, either. I am fervently curious to know the answer to this: if they lack sensory fantasy, would this make them unable to experience flashbacks? If they couldn't, would this potentially help in research into flashbacks?

Thanks, Fran

23 May 2016; 15:45

To: Fran

From: David Pike

Subject: New appointment 

Hi Fran,

Interesting question about aphantasia. Vision tends to be the dominant sense but then there is a constant interplay between primary vision (which detects change, but does not have colour, and cannot accurately identify things) and secondary or focused vision. Primary vision works on pattern matching and 'guesses' what a movement means before we pay attention to it with focused vision (which does have colour and can accurately identify what is going on). Have a coloured pencil handy when we meet and I can show you how this works.

Trauma happens when stuff happens too quickly and we are left with our 'guesses'. Therapy moves our guesses (dysfunctional beliefs) into accurate knowledge with an accompanying sense of relief when we realise what actually happened. But we have to control our emotions until they can let this happen.

Trauma itself involves all the senses including our body defence reactions activated at the time and then these are reactivated in the presence of triggers or cues. All actors know what a cue is. It is a signal that sets off a pre-programmed pattern of learned behaviour.

You do not have to see something to know it is horrible – almost everything we have will be telling us that (e.g. it made the hair stand up on the back of my neck). If you think of something that is mildly traumatic, for the sake of experiment, then whatever senses are available are activated. We can all have things that set stuff off but no memory of why. A friend gets very cold in supermarkets and calls it Raynaud's. We do not know why. I have had strange intense dread walking in innocent countryside but have never stayed long enough to discover why. There is a lot of 'politics' that go on in the unconscious but mine does not tell me about it that often!

Many regards, David Pike

Consultant Clinical & Health Psychologist

30 September 2016; 12:42

To: Fran

From: David Pike

Subject: Just some thoughts 

Hi Fran,

You may already be ahead of me with this, but you went through some extremely deep emotional stuff yesterday. I just want to say that your system will need some time to process this in the background. My 'rule of thumb' is 3 days for the initial recovery period. You may feel 'weak' but that is normal and OK.

It just means be really kind to yourself, do things that are easy or automatic (I call it pottering), do not make any major decisions or make emotional demands of yourself – do those things when the time is right and you feel strong in yourself again. Let yourself be.

I shall be in Sussex with my family and parents from Sunday for a week. Your natural inclination will be to not want to disturb me. I just want you to know I can be reached by email and it is OK if you need to.

Many regards, David Pike

Consultant Clinical & Health Psychologist

30 September 2016; 20:05

To: David Pike From: Fran

Subject: Just some thoughts 

Hi David,

Thanks for your message. I am touched by your words and the care conveyed in them, particularly your offer of email support at the end.

I have been feeling vulnerable. However, I had some empathy off my American friend last night, and then again today from Sally, whom I met on camp. I've also had lots of Whippet snuggles from a tactile Whippet. (Every mental health patient should be issued with a Whippet at the start of therapy!)

Your support and everyone else's have resulted in a striking contrast to how things were for me as a teen, which seems to have helped settle my nervous system.

Thanks for your help, it's much appreciated. Fran

21 September 2017; 07:36

To: David Pike From: Fran

Subject: Yesterday 

Hi David,

When I think about how our Zoom call ended yesterday, I feel sadness. I'm longing for connection, ease, and harmony.

I came off the call and processed with the EMDR and was shaking and crying, and it shifted reasonably quickly.

I would like understanding for how triggering past sexual experiences have been and how these then tie into both my self-trust, volition and feeling safe in the world. Telling me everyone else has made these mistakes doesn't help me determine why I made them and how I can avoid them in the future. I know people aren't omniscient and will, therefore, make mistakes, but I need to know the difference between 'did my conscientious best and still made mistakes' and 'ignoring or not hearing that still, small voice'. I also fear mistakes I will make because I'm not omniscient and how to reconcile that, so my fear doesn't control my life. Is this something you're willing to help me with in relation to my past sexual experiences?

I appreciate you seeing me at short notice, and I realise I didn't express this. I notice my focus turns inwardly when I'm upset.

It's important to me that we resolve this conflict, not least because the more I do so the more agency I realise I have in situations like this. It also helps me to differentiate between relationships where it's important for me to seek resolution (i.e. this one), and those I would be better off without.

I'd be grateful if you would let me know how this landed with you.

21 September 2017; 12:17

To: Fran

From: David Pike Subject: Yesterday

Thanks for getting back to me Fran.

I also felt sadness because, between us, we had done so well and you had come out from the shadows and you were lighting up, but then something happened, I am not sure what, the switch was flipped and you were no longer available to me and nothing I could say would bring you back. I felt as helpless as you did then.

I have known this feeling before and I also know that it does not mean I am a bad therapist – just that this particular session did not end as I would always like – that you felt better at the end than you did at the start. Something more to learn then.

So, you have re-contacted me. You have developed more agency in overcoming the inner state that threatens to overwhelm you and it cannot do so completely now. Its power over you is weakening and every time you do whatever you need to do to re-establish yourself the more you are being your authentic self. The shadows vanish when the light comes from within, anywhere else, even me, and there is always a shadow.

My yoga teacher used to tell me that the Self is perfect and that no work can be done on it. It is omniscient, omnipresent, and omnipotent. How I longed to be that Self. I can honestly say that trying really hard drove me mad. The phrase, 'the sun shines out of his arse' clearly indicated what kind of a yoga teacher I became.

So 'I' may be perfect but, me, I am just a klutz like anyone else on this planet.

Anyway, back to the real world. I felt you made such good progress, but we did not quit while we were winning. Trying to get it perfect by just going on turned into its opposite.

The lesson I drew was that next time, when we get it good, do not try for more. Leave on a high or we risk the low setting in.

Ideally if we can detect the switch then we can see it coming and not go down that route again. Takes a lot of repetition before we get awake enough to see what the switch is. If in doubt keep trying but give yourself time to recover if it goes wrong – do not just get up and throw yourself at the problem before you are ready. At the same time wait too long to get ready and you never really tackle the problem. Now, what can I do that is fun before I have to tackle that problem again?

Safety and trust

At the start of therapy, I was in a catastrophising, downward spiral and this made David's role arduous. These emails helped to develop safety and trust between us at a more profound level than I have experienced with any other therapist. I was far more courageous and articulate via email than during sessions, and I felt they played an essential role in my recovery.

This additional time spent in relationship-building made all the difference when the inevitable conflicts arose. In the emails dated September 2017, my threat detection system had been triggered, and thanks to this email lifeline, I felt sufficiently safe to contact David and tell him what was going on for me, rather than terminate therapy, which is what I otherwise would have done.

Complex trauma had left me with the conviction that I couldn't rely on anyone… that no one cared about me or my welfare, and therefore I had to do everything on my own. This unnatural strategy was overwhelming me and contributing to my severe depression. David's ongoing support outside of sessions helped to transform this; I was able to experience what it was like to feel distressed and have someone who was consistently there for me. The exchanges dated April and September 2016 are examples of this. If David had refused to answer my emails or told me to hold onto it until our next appointment, it would have re-triggered my childhood traumas that I was all alone in the world and that no one was there for me. 

From an outsider's perspective, the emails about aphantasia could be seen as superfluous: I wasn't upset, so surely I was wasting my therapist's time? To me, it was an attempt to connect with him. I had an insatiable curiosity as a child, I wanted to learn how the world worked, but my parents didn't have the time for me. David being willing to respond meant that I received the connection I had been seeking: he 'got' me as a person and gave me the psychological visibility I had been deprived of as a child.

I didn't see receiving additional help outside of therapy sessions as controversial or even particularly unusual. While having therapy through IAPT, so long as I phoned during office hours, I was able to speak to my therapist. I had grown used to being able to get help outside of therapy sessions if I was struggling. This desire for additional support stemmed from the impact that C-PTSD was having on my day-to-day life. Developmental trauma is very different to struggles with life's transitions; it fundamentally impacted my ability to both relate to other people and regulate my own emotions. I would frequently be overcome with intense dread that would come seemingly out of nowhere and torment me for days, or even weeks. I needed a rock-solid relationship with my therapist to feel sufficiently safe to go back to him if he had unwittingly been a trigger. Without this additional communication, I would have inflated any minor therapeutic transgression into a full-blown crisis in the interval between therapy sessions. 

After therapy with David ended due to the imminent death of his parents, I engaged the help of several new therapists in failed attempts to continue therapy. I was never able to establish an affinity with them to the extent that I had with David. This was likely hampered by my still mourning the loss of a therapeutic bond that had come to an end before I was ready. Relationship- building is also laborious for the client, and it was irksome having to build a new one.

One new therapist made it clear that she wasn't available outside of the therapeutic hour. While I do understand that therapists need to protect their downtime, to me her boundary came across as 'you're not important to me and I'm not going to be there for you'. I was unable to develop a connection and we agreed to end therapy after four sessions.

Eight months after therapy with David ended, I sought the help of another clinical psychologist. This is the kind of footnote she had at the end of her emails: Please be aware that we do not provide a crisis service. If you are in need of urgent assistance, please contact your GP or the out of hours crisis service. Alternatively, you can contact the Samaritans on 116 123 or attend the nearest A&E department. Normal working hours are Monday – Friday 10-6pm. I will usually respond to enquiries within 24 hours within these times. Whenever I attempted to engage with this therapist via email, I received only a brief response. My parents' indifference towards me, mirrored again. I didn't have this in my conscious awareness at the time, so it wasn't something I was able to raise in therapy. I stopped working with her after only eight sessions when we lost the connection. If I'd had an email lifeline with her, I may have been able to express my misgivings first to see if we could resolve them, but due to complex trauma magnifying the threat of conflict, confrontation in person was just too intimidating for me.

I'll end with a note on David's thoughts, which he has included below. As a client I can't think of anything worse than being suicidal and having to deal with strangers rather than being able to speak to my therapist. I wonder if therapists who work with complex trauma could find an equilibrium, between helping the client based on need and still maintaining their own work-life balance?

From David Pike…

'I also benefited from replying to Fran's emails, as they enabled me to reflect more deeply on what I was doing – therapy-wise – and why I was doing it; as well as helping us both make more meaning out of our lives. Our conversations were an intellectual discourse, meaningful to me, as well as to Fran. Even though I was the one in the position of authority, I was willing and ready to learn too, particularly from her experience with communication. That resonated with Fran: she told me 'One thing I hated as a child was adults being uppity when I knew something they didn't'! 

I worked for many years in Public Sector roles, mostly prior to the internet and emails. I know that, for example in some psychosis teams, it is not that unusual for psychologists to give out their personal contact details. But in my supervision experience of other therapists, however, there often seems to be a potentially irrational fear of unspoken professional guidelines that we aren't supposed to let clients contact us in between therapy sessions: if it's deemed as inappropriate contact with a client by other therapists and, therefore, unprofessional, we may be subjected to disciplinary action. The Boundary must be impermeable.

It seems to me therapists often don't want to be contacted outside of therapy due to fear… "If I give clients my email address, they can potentially reach me at any time'. After 50 years of experience, I minimise the fear of abuse by ensuring that communication is as good as it can be and that we are always in agreement as to what I am providing and what our goals are, even if things change over the course of therapy. We are both signed up to 'the rules'. 

The fear of distressed clients misusing such a facility is overblown, in my opinion. Fran wasn't the only client where I have had this means of communication in place and I have not had any client who abused it. Indeed, I have had a suicidal client contact me during unsociable hours: 11.30pm on a Saturday night. I did take her call and I'm very glad I did as it prevented her suicide. The difference with Fran was that it turned into mutually enjoyable conversations on a human-to-human level, not just the clarification of stuff that came up in therapy. These are our private conversations, never intended for publication.

The last point is about clinician burnout. There is a need to close off mentally from the client so that work doesn't take over your life. To be 'always on' ready to take another emergency call and never take a complete break is to deplete one's own resources. In my case, the burnout danger is a valid point; I called a halt to sessions with Fran when my parents were dying and I was being run ragged. However, I love being therapeutic and this passion seems to protect me most of the time.'

- How do you handle these types of boundaries, as therapist or client? Join the conversation @psychmag on Twitter.