Trauma-Related Disorders

Abstract

In order to achieve success in addressing post-traumatic disorders, all psychotherapy methods must deal with the dissociation and flashbacks of these patients in a disorder-specific manner. The patient should learn to free himself from flashbacks in psychological crises through self-stabilization techniques. When narrating a traumatizing situation, he should reflect on what he would have needed in the situation instead. He should rewrite the traumatizing situation into a coping fairy tale. The basis of trauma processing is the dissolution of dissociation through the focused external role change between four different metacognitive processes - the patient’s ego in the control and information space, his ego in the observation and narration space, his ego in the interaction space between perpetrator and victim, and his ego in a safe place. In this way, the patient dissolves his metacognitive confusion. He gains ego control over his dysfunctional self-regulation in the as-if mode of play. Psychodramatic acting in the as-if mode is more healing than purely verbal therapy. This is because the patient differentiates and completes the cognitive thought content in the traumatizing situation in psychodramatic action on the psychosomatic level of sensorimotor patterns of action, physical sensations, and affect. Or he completes the psychosomatic level of experience with the associated linguistic terms and thoughts to form a meaningful narrative. The disorder-specific psychodramatic action methods qualitatively enhance the depth psychological, behavioral, and systemic psychotherapy of people with post-traumatic disorders.

5.1 What is Special About Trauma Therapy?

Psychological trauma can result in different clinical disorders: post-traumatic stress disorders, anxiety disorders, obsessive–compulsive disorders, depression, personality disorders, psychosomatic complaints, addiction disorders, and psychotic episodes (see Sect. 5.2). Therefore, in such cases, the therapist should also use trauma therapy elements in psychotherapy, if necessary.

Recommendation

Therefore, a causal treatment of these disorders includes methods of trauma therapy described in this chapter. The more experienced a therapist is, the more courageous she becomes to perceive and process the trauma.

Central idea

“All professionals in the field of trauma therapy agree that we must adapt conventional psychotherapeutic methods to meet the needs that arise from traumatic stress. This means that conventional psychoanalytic or behavioral therapy does not meet the needs, but neither does conventional family therapy, gestalt therapy, body therapy, etc.” (Reddemann & Dehner-Rau, 2004, p. 77). The reason is the defense of dissociation in the case of trauma-related disorders (see Sect. 5.10.2).

Special experiences in the treatment of people with trauma-related disorders are:

(1) Those affected dissociate as soon as their trauma experiences are ‘triggered’ by external events. As a result, they experience the current situation in the equivalence mode as if they are being traumatized in the present. (2) The flashbacks repeatedly lead to crises in the therapeutic relationship, thereby collapsing the therapeutic progress. (3) Unrecognized flashbacks discourage both the therapist and the patient, resulting in negative transference and countertransference reactions. (4) Patients with trauma-related disorders suffer from the impact of their trauma. However, often they do not give their trauma any meaning. (5) Some of the behaviors and ways of thinking in trauma patients appear to be neurotic at first. However, in truth, they are useful and helpful for the patient. They are self-stabilization techniques that protect him from slipping into a flashback and feeling like he is losing his dignity or being scared to death. (6) Flashbacks are often triggered by very small scenic stimuli. These stimuli resemble memory fragments from the trauma situation. For example, a specific smell or the sight of a man in a white coat triggers a flashback sometimes.

Case example 32

The 67-year-old Mr. A. sought outpatient psychotherapy to treat his recurrent moderate depressive episodes (F33.1). Five years ago, his thyroid had been removed because of cancer. He decompensated into depression once again four weeks ago. This was triggered by a regular check-up concerning his cancer. He groans in agony in the psychotherapy session: “It was good all summer! I could really enjoy the time! But now I am again powerless, resigned, and helpless. I'm afraid!” The therapist understands the patient's depression as the result of retraumatization: the patient contracted polio meningitis when he was a four-year-old little boy. He had to spend eight months alone in an isolation room in the hospital. His family was not allowed to visit him. Doctors and nurses clothed in white ‘attacked’ him at regular intervals. They held him with physical force and stabbed him with a syringe in the back to withdraw nerve fluid from his spinal canal. At age 67, if Mr. A. sees a man in a white coat, he again experiences a flashback. The therapist recognizes the flashback through the significant negative effect of a small specific scenic trigger. His flashback does not occur if he sees a woman in a white coat or a man in a green coat.

Mr. A. hates himself in his depression because of his ‘weakness’. He comments sarcastically: “I am obedient again.” The therapist feels helpless in the face of the patient's depression. In the beginning, he interprets his behavior as a neurotic adaptation. He asks why Mr. A. is still doing the follow-up examinations for cancer more than five years after his operation: “Your cancer never metastasized. If the doctors offer you check-ups, you blindly obey them! Your depression is telling you that you are going in the wrong direction!”.

Two weeks later, Mr. A reports: “I canceled the last follow-up. But I did it because of the flu. My wife encouraged me to do this. I felt as helpless and dependent as a child! I needed someone who would allow me to do that!” Only now does the therapist realize that the patient felt and behaved like the little four-year-old boy in the hospital during the last therapy session. In his flashback, he had been unable to engage in healthy adult thinking (see Sect. 4.7). The therapist apologizes: “I'm sorry! It was unfair of me to get angry and ask you to be less conformist. You couldn't help it! When you are having a flashback, you have no choice. It is as if you are sleepwalking under hypnosis.” The therapist places an empty chair next to the patient. He places the hand puppet of a little boy on it and points with his hand to this second chair: “The chair represents the little four-year-old boy in you who is traumatized.” The patient looks at the doll and is visibly annoyed. The therapist: “I notice that the chair for the little traumatized boy is too close to you. I'll put it here in the corner of the room.” The therapist and the patient work together to find indications for the flashback. The patient writes them down: (1) “When I feel like a child again.” (2) “When I feel lethargic again.” (3) “When I internally feel: You must be nice!” (Continuation in Sects. 5.5 and 5.9).

5.2 Definitions of a Trauma-Related Disorder and a Traumatizing Situation

According to the ICD-10 (2004, p. 187), post-traumatic stress disorder (ICD-10 F43.1) (PTSD) arises “as a delayed or protracted reaction to a stressful event or a situation of shorter or longer duration with an extraordinary threat or catastrophic magnitude that would cause deep despair in almost anyone. […] The beginning follows the trauma with a latency lasting from a few weeks to months. […] In a few cases, the disorder takes a chronic course over many years and then turns into a permanent personality change (F62.0).”

There are two main forms of coping with psychological trauma–internalization and dissociation. Analogous to this, one can differentiate between two forms of trauma-related disorders, (1) relationship trauma in childhood and (2) post-traumatic stress disorder caused by trauma in adulthood. Patients who were traumatized in childhood often suffer from borderline personality disorder (Mentzos, 2011, p. 170), another personality disorder, depression, or anxiety disorder. These patients are fixed in a mutually stabilizing defense system of masochistic self-censorship and compensatory mechanisms (Mentzos, 2011, p. 39) that they developed as children in response to their childhood trauma. The defense system helped them avoid giving meaning to the traumatic experiences. Self-protective behavior (see Sect. 4.7) includes defense through grandiosity, perfectionism, or functioning in the role assigned from the outside (see Sect. 4.7). Patients with post-traumatic stress disorder because of trauma in adulthood have not yet developed a rigid defense system.

• 1. Direct traumatization in childhood occurs through sexual abuse, violence, or severe experiences of loss. These events mostly take place in the family context. Indirect traumatization in childhood occurs when a child is physically and emotionally neglected by traumatized or severely mentally ill parents. The child then experiences his wishes and needs as ‘wrong’ and thus develops reactive masochistic self-censorship and defense through grandiosity and perfectionism to avoid rejection by emotionally unstable caregivers. In adulthood, this leads to masochistic thinking and acting (see Sect. 8.5). The unseen, “abandoned child” could not sufficiently develop the tools of his inner conflict processing in interacting with his childhood caregivers.

  Traumatized children cope with the trauma through internalization (Hirsch, 2004, p. 2). “A traumatic introject persists, threatening like a dreadful hostile, archaic superego (causing symptoms and pathological behavior), which is only partially held in check by various forms of identification with the aggressor (primarily fusing and secondarily identification)” (Hirsch, 2004, p. 1). Those affected internalize their trauma experience in the form of a perpetrator-victim complex.

• 2. Patients with adult-onset post-traumatic stress disorder (PTSD) suffer from flashbacks in response to even minor external triggers. They cope with their trauma through dissociation. A sudden, extreme impact of violence had initially overwhelmed their psychic apparatus. They split off their observing ego (their cognitive processes) from their acting ego (the perception of affect, physical sensations, and sensorimotor interaction patterns) when dissociating (see Sect. 5.4). This helps patients survive mentally, at least in the beginning (Hirsch, 2004, p. 2). However, dissociation persists as a response and becomes a permanent pathological defense if the trauma is not processed. As a result, the clinical picture of post-traumatic stress disorder develops with recurring flashbacks.

Important

Three conditions define a traumatizing situation: (1) The person concerned is emotionally overwhelmed by the situation. (2) He cannot fight and (3) He cannot flee. He, therefore, cannot physically act to protect himself.

Case example 33

Kurt Lewin (Hans-Ulrich Wolf, 1999, oral communication) reported on school children locked in a cave while visiting the cave. The teacher was outside the cave when the entrance to the cave collapsed. All children suffered from post-traumatic stress disorder after their rescue. Only one boy was not affected. They investigated why this child had processed the event differently than the other children. It turned out: this boy had not been overwhelmed with panic like the others and had not just waited passively. Instead, he continued to look for an exit from the cave. Eventually, he found an exit and led the other children out of the cave. A short while later, the cave collapsed completely. So the boy wasn't frozen in shock. He had acted and tried to change the threatening situation.

The same happened to a cashier and his colleague in a bank robbery. The cashier kept negotiating with the perpetrator about handing over the money. But, his colleague hid under a table in panic and feared the perpetrator might discover her at any moment and shoot her. Unlike his colleague, the cashier did not develop any post-traumatic stress disorder afterward.

Recommendation

Therapists should know which events can potentially traumatize a person.

Gunkel (1999, p. 54 ff.) has made a list based on international literature: 46–78% of Holocaust victims are traumatized. 30% of soldiers who experienced combat missions and 12% of soldiers without any experience of combat mission suffer in retrospect from a trauma disorder, 16–35% of Vietnam veterans, 10–20% of Canadian UN soldiers, 25–50% of refugees, 31% of victims of state repression or violence, 90% of political prisoners from Vietnam who have experienced torture. Three months after sexual abuse or rape, 48–80% of those affected have a trauma-related disorder, four times as often in sexually abused children as in physically abused children. 10–23% of the bus drivers who were attacked while driving suffer from a trauma-related disorder. 7–34% of police officers develop trauma-related disorders after rescue missions or violent experiences, for example, 31% after the collapse of a grandstand. 16% of those affected develop post-traumatic stress disorder after a cardiac infarction, 13% after heart transplants, and around 10% after blood cancer treatment. Between 30 and 40% of parents suffer from trauma-related disorders after treating a child with cancer, between 18 and 23% after traffic accidents, 22% after a plane crash, 5–42% after natural disasters such as earthquakes, and 14% after losing a close reference person. There is also a high trauma potential if one was unwanted as a child, had to experience cancer themselves, or had to provide long-term care for a seriously ill family member. Patients with post-traumatic stress disorder (PTSD) have often experienced not just one but multiple traumas in their life.

Central idea

PTSD can be a result of accidents or natural disasters. Trauma experiences caused by violence by people are more likely to result in PTSD because those affected also lose their basic trust in relationships.

Not everyone is traumatized by a potentially traumatizing event. The percentages in the list above show this. The consequences of traumatizing events depend on (1) the age at which the traumatizing event occurs, (2) the severity and duration of the traumatizing events, and (3) the number of traumatic events the individual had to experience. A history of mental illness can lower the threshold for developing a trauma-related disorder. The patient's psychological resilience is an important protective factor. Sensitive people are more easily traumatized.

Case example 34

A student who was repeatedly depressed for months sought help in an esoterically oriented group that offered ‘guided regressions’. The group members searched for their own experiences of violence in their ‘past lives’ under the guidance of a ‘guru woman’ who seemed to be traumatized herself. Anyone who did not participate in the ‘regression’ or left the group was considered ‘evil and devilish’. After spending six months in this community, the student decompensated into paranoid psychosis. The sensitive young woman had not been able to endure the tension of the conflict with the idealized ‘master’ and had collapsed mentally. She was convinced that the sect's leader had become influenced by extraterrestrials and became ‘evil’. That was a true symbolic image of the actions of the ‘master’. But, the student experienced this symbolic image as an external reality in the equivalence mode (see Sect. 2.6).

5.3 Symptoms of Trauma-Related Disorders

According to Gunkel's review of the literature (1999, pp. 54 ff.), around 5% of male and 10% of all female Americans develop post-traumatic stress disorder as a result of a traumatic event at some point in their lives. Around 26% of bulimia patients have experienced sexual assault or rape and suffer from trauma-related disorders, as do 68% of prostitutes and 52% of patients with eating disorders. Around 35–52% of persons with psychotic disorders suffer from trauma-related disorders four to eleven months after an acute phase of illness, as well as from ‘invasive psychiatric treatments’. According to the study, 30–90% of people with borderline personality disorder are traumatized. According to a more recent review (over 53 studies) by Simpson and Miller (2002) (quoted from Schäfer & Reddemann, 2005), 27–67% of women and 9–29% of men with addictions were sexually abused in childhood. 33% of women and 24–33% of men with addictions were physically abused in childhood. A Dutch study of patients with alcoholism demonstrated that 28% of men and 46% of women experienced physical or sexual violence or physical and sexual violence in childhood.

According to Reddemann (1999, p. 88), traumatized people suffer from constant agitation (DSM-IV criterion D: ‘hyperarousal’) and sleep disorders. They are easily vulnerable, excessively nervous, and find it difficult to calm down. They are constantly in fear, are easily insulted, and are less capable of dealing with conflict, especially when the topics of conflict are related to their traumatic experience. “The repeated experience of the trauma in the form of intrusive memories (DSM-IV criterion B: intrusions) […] against the background of a constant feeling of numbness is characteristic of people with traumatic experiences” (ICD-10). ‘The Broca speech area is not activated or not sufficiently activated during a flashback. In other words, speech and language are not or hardly accessible” (van der Kolk & Fisher, 1995). People with traumatic experiences exhibit one or more of the following symptoms: acute anxiety states, depression, multiple psychosomatic symptoms, somatization disorders, phobic or compulsive behavior, a constant feeling of numbness and emotional dullness, recurring nightmares and flashbacks, outbursts of anger, indifference in interpersonal relationships and the inability to love, mysterious behavior, drug or alcohol abuse, distracting, ‘sensation-seeking’ lifestyle and/or dissociative states with depersonalization and derealization through to mini-psychoses. Avoidance (DSM-IV criterion C) of activities and situations that could trigger memories of the trauma is also pronounced. Thoughts of suicide are not uncommon. Often there is an unconscious wish to control everything to avoid being helpless at the mercy of a threatening or chaotic situation again.

5.4 Dissociation as a Central Characteristic of Trauma-Related Disorders

Important definition

According to van der Kolk and Fisher (1995), the ‘nature of trauma is to be dissociative’. People with relationship trauma in their childhood also dissociate when their trauma experience is triggered (see case example 32 in Sect. 5.1).

Central idea

For people with traumatic experiences, dissociating is “like everything that we can later describe as pathology [...], a normal way of coping with the trauma” (Reddemann, 1999, p. 87). It helped those affected by the original traumatizing situation to detach themselves from the overwhelming and destructive feelings and to experience the trauma as if it happened to someone else (Putnam, 1988, p. 53).

“When the physiological mechanisms of fight and flight no longer work, the only thing left for humans is dissociation as a quasi-psychological flight mechanism. […] Traumatized people often describe these experiences by reporting that they left their bodies in the traumatic situation” (Reddemann, 1999, p. 87). “Dissociation leads to the trauma memories […] being organized as sensory fragments and intense emotional states […]” (van der Kolk et al. 1996). Dissociation in the traumatizing situation can help those affected still function externally and, for example, save their lives (see case example in Sect. 5.17.2). The consequence, however, is that later the trauma experience is not processed like other experiences because the patient immediately dissociates when attempting to deal with the trauma. His ability to process conflict freezes. In the case of post-traumatic stress disorder, the traumatic memories often only become conscious in a new, protected environment. By definition, however, they are then unprocessed. Those affected get caught in the vortex of their unprocessed trauma memories and are tormented by their trauma images. Even small triggers evoke the dissociation again. Dissociating becomes a symptom.

Central idea

According to Reddemann (1999, p. 89), the agonizing thing about flashbacks is “that they are experienced as if they were happening now, which means the reliving of traumatic states is not remembrance, but retraumatization.” “Triggered by a memory, the past can come alive with sudden sensory and emotional intensity such that the victim feels as if the entire event is happening again in the present. Patients with PTSD seem trapped in their trauma and cannot distinguish it from the present” (van der Kolk, Burbridge, and Suzuki, 1998, p. 58 f.). They experience their flashback in equivalence mode (see Sect. 2.6).

Dissociating is a “complex psycho-physiological process involving the disintegration and fragmentation of the consciousness and […] the memory, the identity and the perception of oneself and the world around” (Gast, 2000, p. 170). According to Gast, there is a distinction between five main dissociative symptoms: amnesia, depersonalization, derealization, identity insecurity, and identity change.

A flashback with dissociating leads to an uncontrollable full-blown stress reaction. If the fear is uncontrollable, the hippocampus in the human brain begins to pull in the extensions of its nerve cells (Hüther, 2002, only from oral communication). In people with severe post-traumatic stress disorder, the hippocampus volume can decrease by 8–22% (van der Kolk et al., 1998, p. 69). This leads to hyperexcitability and disinhibition of behavior because it is more difficult to bear and process emotionally arousing information with a reduced hippocampus volume. Those affected often estimate new stimuli as a general threat and react immediately with aggression or withdrawal (van der Kolk, Burbridge, and Suzuki, 1998, p. 72).

Important definition

Wurmser (1998, p. 425 f.) has developed a definition of dissociating that captures several metacognitive processes. He understood dissociating as ‘a form of a split between the observing and acting egos with depersonalization as an important event. This split or dissociating involves a massive denial of inner reality, namely overwhelming emotions (blockade of emotions). Other forms of defense also play a role but pale in comparison to the defense through denial/blockade of emotions. This also includes a counter-fantasy that supports denial and is intended to invalidate the perception of reality’.

Central idea

When dissociating, those affected split the current psychosomatic resonance circuit (see Sect. 2.7) in the internal process of self-development in the external situation into (1) the cognitive process of thinking and naming and (2) the psychosomatic process of sensorimotor interaction, physical sensation, and emotional experience (see Sect. 2.7).

5.5 The Therapist Witnesses the Traumatization and the Dissociating

Many patients with trauma-related disorders ascribe no meaning to the traumatic events in their mental development. They defend through denial and don’t talk about it either. Because if they did, they would potentially activate the associated psychosomatic resonance pattern and with it their unprocessed panic, horror, and alienation of the traumatizing situation and have a flashback. Traumatized patients thus feel defenseless in response to the trauma-related symptoms. They aren’t able to do anything which further intensifies the symptoms. They are afraid of going crazy when they have a flashback. But they ‘don’t want to burden other people with their problems’. They are ashamed of their ‘abnormal’ thoughts and feelings. They notice that they are different from others and fear being excluded from the community. Only 2.9% of the soldiers in the German Armed Forces allegedly suffered from post-traumatic stress disorder after a deployment in Afghanistan (Schulte-Herbrüggen & Heinz, 2012, p. 557). But 9–20% of American soldiers developed depression or post-traumatic stress disorder after deployments in Afghanistan (Wittchen et al., 2012, p. 559), 14% of them even became seriously ill (Süddeutsche Zeitung, December 20, 2011, p. 9). Many US employers are reluctant to hire veterans from the Iraq wars because of the reputation of emotional instability that precedes them. Presumably, German veterans only rarely talk about their trauma experience because they rightly fear the hindrances in their promotion in the Armed forces.

Central idea

Patients with PTSD develop masochistic self-esteem issues or compensatory behaviors in response to their flashbacks. The therapist must not interpret and treat a traumatized patient’s self-esteem issues or depressive inhibition as neurotic because that often intensifies the patient’s depression.

Recommendation

The therapist informs the patient as early as possible that his depression results from a traumatic experience and puts a second chair next to him for his traumatized ego (see Sect. 5.8): “The chair symbolizes your traumatized ego and your trauma film. You don’t understand yourself because you experience flashbacks even with small triggers. This causes you to devalue yourself in addition to your traumatic experience.”

The patient needs at least five therapy sessions to integrate the terms “trauma” and “flashback” with his own life experiences. But then he feels relieved, re-interpreting his symptoms. He no longer feels defenseless in response to the trauma-related symptoms because he can act. The therapist and the patient develop a plan for trauma therapy. The masochistic vicious circle disintegrates gradually. The patient understands himself for the first time. He develops a new motivation for therapy. The new self-knowledge opens therapeutic access to the patient’s psychodynamically important conflicts.

Case example 32 (1st continuation, see Sect. 5.1)

In the first interview, Mr. A massively devalued himself because of his internal depressive paralysis: “Actually, I just want some peace! But my wife always criticizes me for being so withdrawn. I should play some sports and pursue some hobbies. I want that, but it doesn't work! We quarrel quite often.” While taking the case history, the therapist discovered the trauma the patient experienced when he was four. He placed a second chair next to him and placed the puppet of a little boy on it: “Mr. A., that's the little boy in you who, at the age of four, had to spend eight months alone in an isolation room in the children's hospital. I suspect that you were traumatized by this dire experience as a child! How do you feel when you see the little boy you were, sitting over there on the chair?” Mr. A: “Not so good.” The therapist places the chair of the ‘traumatized child’ in the other corner of the room behind the window curtain: “I think it is better for you this way! Otherwise, the old memories will flood back to you.” The therapist places a second empty chair next to him and places the hand puppet of a knight on it: “This other chair represents your self-protection through adaptation and grandiosity. You learned in childhood not to give meaning to your trauma experience. You were a brave hero who could do anything and take anything.” The therapist points his hand to the ‘traumatized child’ behind the curtain: “But now, if you go to the clinic for a follow-up examination and see the doctors’ white coats, you slip into your old trauma film. You feel and think like you did when you were four years old! Please, just read about trauma and flashback on Wikipedia!” Mr. A. initially reacted skeptically. But he then gave more details about his experiences at the age of four. He came home after the hospital stay and longed for safety and security as a four-year-old boy. But his mother immediately sent him with his grandmother to the Black Forest for a cure. He was supposed to learn to walk again after polio. The patient's parents were rigidly fixated on the old norms and values from World War II. It was only his performance that mattered to them. His father had been a hero in the war.

After two years of individual therapy, the patient finally saw himself as ‘traumatized.’ The patient's ‘depressive phases’ had disappeared except for the week he went for a medical follow-up. Mr. A. enjoyed his life and, for example, played creatively with his grandchildren. His wife, a former nurse, understood him better now. She allowed him to be different from others and to withdraw when necessary. The patient no longer devalued himself masochistically. He had developed a good relationship with his inner traumatized little boy. Mr. A. also informed the hospital doctors about his trauma disorder. He negotiated special conditions for himself. For example, he ensured he did not have to wait five hours for the examination in the outpatient clinic as he usually did. He had always met a lot of men in white coats there. But now, he would be the doctor's first patient to be examined at eight o'clock in the morning. The doctor spontaneously offered that he would take off his white coat. During his follow-up, the patient remained in the hospital alone in an isolation room for three days because he was injected with radioactive substances as a precaution to combat possible metastases. But he got a hospital room on a higher floor with a better view. And he was allowed to go for a walk in the park on the third day but could not approach other people that day because of his radioactive radiation. The patient thus experienced that, unlike in childhood, he could change his unbearable situation in the hospital of his own free will. He had gained some control over the retraumatizing situation. (continued in Sect. 5.9).

Central idea

In metacognitive psychodramatic trauma therapy, the therapist symbolizes the patient’s traumatized ego with a second chair next to him. In this way she separates his psychosomatic resonance pattern in the traumatizing situation there and then from his psychosomatic resonance pattern here and now in the therapeutic relationship. A psychosomatic resonance pattern includes the inner sensorimotor interaction pattern, the physical sensation, the affect, linguistic concepts, and the thoughts in the external situation (see Sect. 2.7). In the two-chair technique, the patient and therapist stand shoulder to shoulder and look at the patient’s traumatic experience from a meta-perspective. This strengthens his cognition. He can talk and think more freely about the traumatic event. Without the second chair, the two psychosomatic resonance patterns would mix and most likely cause a flashback.

By naming and externally representing the ‘traumatized ego’ with a chair, the therapist becomes a witness to the truth of the patient's existential need. She acts retrospectively in the present as the patient's close caregivers should have acted in the past. Often a witness to the truth is missing during or after the traumatic event. The caregivers looked away. They were comfortable or fearful of aggression. But the therapist, as the witness, pays attention to what happens. She calls a spade a spade. She stands by the victim's side. Experience shows that this reduces the secondary self-devaluation after a traumatizing experience (Mentzos, 2011, p. 38 f.). Self-doubt arises, for example, when a mother actively looks the other way as the father sexually abuses their daughter. Everyday life in the family goes on as if nothing had happened. The abused girl then secondarily begins to doubt whether the crime actually took place. Or the girl believes the perpetrator that she herself ‘wanted’ or ‘provoked’ the sexual assault. In such a case, the victim develops a false self-image. The traumatized child needs a witness to the truth, who validates their feelings of betrayal, fear, and shame as a victim and counteracts unjustified feelings of guilt.

Central idea

In metacognitive trauma therapy, the therapist is an implicit doppelganger in the patient’s inner process of self-development in the external situation (see Sect. 2.5). She must actively decide whether or not she wants to understand the patient’s adverse experiences from adulthood or childhood as traumatic experiences. If she decides to do so, as a witness of the truth in her interaction with the patient, she calls the spade ‘a spade’. This, at least retrospectively, removes the secondary insecurity of the patient caused by the flashback.

Case example 35

A 42-year-old patient gave the therapist feedback in the final therapy session: “In the beginning, the work on the relationship with my partner was actually a skirmish. However, there was a turning point for me in therapy. This was when you told me that my experiences with my father in childhood were a trauma. That's when my experiences became real for me. That gave me the right to feel what I feel. I believed that my fear of death was a real fear of death from the physical abuse by my father. That it was true! Before, I thought: ‘You have to pray! Others have it worse!’ By naming it as ‘Trauma’, you took me by the hand and walked with me for a while. It hurt me! But it was a crucial moment. I got to the core of it myself. I opened the door to my inner child, who was sitting behind the door: I opened the first door first. The child wasn't there. Then I opened the second door. She wasn't there either. She wasn't behind the third door either. But then there she was, behind the fourth door, sitting fully wet and feeling afraid!” (Continued in Sect. 5.15).

Some therapists avoid openly naming a patient’s trauma and flashback directly in front of the patient. They fear that it will retraumatize the patient. In doing so, they unconsciously identify with the patient’s defense through denial and act out countertransference. But in patients with trauma-related disorders, dissociating contributes to the development of symptoms. Therefore, it is essential to treat dissociation in psychotherapy.

5.6 The Seven Phases of Psychodramatic Trauma Therapy

Recommendation

“Trauma is chaos, and chaos needs structure” (Reddemann, 2007, only oral communication). The patient had no influence on the traumatizing event in the traumatic situation itself. In therapy, he should therefore have control over what happens to him. The individual steps of trauma therapy are to be discussed openly and clearly with him.

The therapeutic approach can ideally be divided into seven consecutive phases (see Fig. 5.1): (1) The preliminary phase of trauma therapy addressing the patient’s defense system (see Sect. 4.10), (2) Trauma-specific diagnosis, (3) Trauma-specific crisis intervention, (4) Learning self-stabilization techniques, (5) The processing of trauma with exposure to trauma, (6) the phase of integrating the inner change into childhood and current relationships, and (7) The therapist and the patient work on the defense system developed in childhood (see Sect. 4.10) in order to free the self-development from its fixation.

Fig. 5.1

The six phases of psychodramatic trauma therapy

Many patients with trauma-related disorders come to therapy with a diagnosis of personality disorder, anxiety disorder, depression, or addiction disorder. Often the therapist only notices it first during the treatment that the patient is suffering from a trauma-related disorder. A trauma-specific diagnosis (see Sect. 5.7) and learning the self-stabilization techniques require at least ten individual sessions. This work can also be done by consultants from the helping professions. But, one should proceed with processing the trauma (see Sect. 5.10) only during long-term therapy of more than 30 sessions. It requires further training as a psychodrama therapist.

Central idea

In the mentalization-oriented psychodrama therapy of trauma-related disorders, the therapist always works also metacognitively. She lets the patient realize the metacognitive processes of his dissociating in the as-if mode of play and focuses on them in her therapeutic communication (see Sects. 2.14 and 5.10).

Patients who suffered relationship trauma in their childhood developed permanent mutually stabilizing compensatory mechanisms and masochistic self-censorship (see Sect. 8.5) to help them cope with their lives to some extent. Their rigid defense patterns often lead to severe relational disorders, depression, or anxiety disorders. But, the patients experience their defense through perfectionism and grandiosity and their self-censorship as parts of their character and identity (see Sect. 4.2). They couldn’t internally develop a concept of appreciation in relationships in childhood. They, therefore, give no meaning to their traumatic childhood experiences. For example, they often see their traumatizing parents as ‘loving parents’. They also perceive their unfortunate living conditions in the present as ‘normal’ and their ‘personal fate’.

Central idea

In the preliminary phase of trauma therapy, patients with trauma-related disorders must often first work on their defense through grandiosity, perfectionism, and masochistic self-censorship. This is the only way they gain access to their childhood traumatic experiences (see Sects. 4.8 and 4.10).

5.7 Trauma-Specific Diagnosis

Patients with childhood relationship trauma often come with presenting complaints of anxiety, depression, severe relationship disorders, or an addiction. Mostly they do not know that they are suffering from a trauma-related disorder. The therapist may recognize the traumatic quality of the patient's childhood experiences, perhaps while taking the case history. But if she works with the patient empathically during therapy, she often unknowingly takes over the patient's defenses and ‘forgets’ to give his trauma experiences sufficient attention.

Central idea

Only when the symptoms persist for a considerable period, and there are noticeable disruptions in the therapeutic relationship, the therapist becomes aware of something essential still missing in the therapy process. In such a case, the therapist can use steps 13–17 of psychodramatic self-supervision (see Sects. 2.9 and 4.8) to identify the patient's dominant defense pattern.

Recommendation

If during therapy, the therapist suspects that the patient's symptoms, for example, his depressive episodes, may reflect a trauma-related disorder, she re-examines the patient's diagnosis.

The following therapeutic experiences indicate a trauma-related disorder: (1) The patient repeatedly decompensates psychologically. (2) The extent of the psychological breakdowns is difficult for the therapist to empathize with and does not match the seemingly harmless triggering circumstances. (3) The patient exhibits symptoms of a trauma-related disorder (see Sect. 5.3). (4) He is unusually distant in verbal communication or cannot be reached emotionally. (5) The therapist feels incapable, helpless, strange, or mystified in the therapeutic relationship. (6) If the therapist represents the ‘inner child’ of a patient with childhood trauma with a second empty chair (see Sect. 4.7), the patient rejects his ‘inner child’ instead of addressing him (see Sect. 5.8).

Recommendation

The therapist must not depend on the patient's consent when diagnosing a ‘trauma-related disorder’ because many patients ascribe no meaning to their trauma experience. If they did that, they would get caught in their flashback or activate their inner ‘blind sadistic prosecutor’ (see Sect. 4.7). Therefore, the therapist first decides on her own whether she perceives the patient as traumatized.

Some conspicuous, apparently pathological behaviors of the patient are to be understood as necessary self-protection through self-stabilizing actions. The therapist may reinterpret them in a radically positive way. For example, the therapist spontaneously sees a 90-h workweek in a person with neurosis as problematic and questions it. In the case of a patient with trauma, however, she interprets it as a ‘self-discovered technique of self-stabilization in the case of a trauma illness’.

Working with the table stage (see Sect. 5.10.10) helps to gain an overview of the interaction between the existing conflicts when making a diagnosis. The technique of the self-regulation circle (Krüger, 2010a and see below) is indicated to retrace the patient’s self-regulation in recurring conflicts and recognize any flashbacks that occur in the process. The chair work (see Sect. 4.7) helps to increase the patient's awareness of his defense through adaptation, grandiosity, and masochistic self-censorship.

The therapist works as follows when working with the self-regulation circle:

(1) She puts an A3 size sheet of paper on the table and draws a large circle on it. (2) She marks the crisis with a minus sign on the right side of the circle and the patient's well-being with a plus sign on the left. She marks the conflict process with an arrow, from the positive pole to the negative and vice versa. (3) The patient then notes his thoughts, feelings, actions as well as the events, step by step, along the circumference on the right side indicating the way into and on the left side indicating the way out of the crisis: “What did I do? What did I feel? What did I think? What did I want then? Then what happened? Then again what did I do? … feel? … think? … etc.” The patient uses the self-regulation circle to understand his recurring conflicts: What is his contribution to causing the crisis? But also, what is his contribution to becoming well again?

Case example 36

The 28-year-old Mrs. A seeks crisis intervention because she is ‘feeling bad again’. She has had several traumatic experiences in her childhood and youth. She struggles with borderline syndrome with reactive psychotic episodes (F60.31). The small, pretty woman looks exhausted and depressed. She reports: “I have hardly slept in the last 14 days. Therefore, I had to go home yesterday while working in the supermarket. I messed everything up. Everyone points their fingers at me. They want to test me!” The therapist makes an offer: “Together, we could examine and make a note of what happens when you have mood swings.” The patient creates a self-regulation circle. At the end of their collaborative work, the following is written on the paper along the circumference from well-being to crisis: (1) “We are going to my grandma's home unannounced. (2) She is happy. (In her childhood, the grandmother was the only one who gave the patient support and security in the broken family.) (3) My husband is nice. Grandma is doing fine. I am fine. (4) The vacation is over. We are driving home. (5) I'm afraid that people at work won't want me. (6) I have trouble sleeping, have stomach cramps, and I panic. (7) I am afraid of failure and being a bad mother to my son. I have diarrhea. (8) I am afraid of being considered lazy. (9) I am constantly afraid that other people will see what is happening to me and laugh at me. (10) I play something for everyone. They shouldn't notice anything. (11) Nothing works at home anymore. (12) Nothing is fine at work. (13) I think other people are testing me.”

On the way from crisis to well-being, the patient notes: (14) “Shame motivates me to perform. (15) I am afraid of being considered evil. That's why I try to be a good person. (16) I work a lot and work overtime without pay. I am good at home and a good mother. (17) My self-esteem increases. I'm doing fine. (18). But I feel bad when I have nothing to do.” The therapist positively interprets the patient's imperfect solutions as ‘self-discovered self-stabilization techniques’. This stabilizes the patient. She feels understood and gains distance from her dysfunctional actions and feelings during the crisis. She even smiles a little at the end of the session. She takes home the paper with the self-regulation circle.

Five days later, Mrs. A. reports spontaneously in the following therapy session: “I have discovered something. Something is still missing in the circle: When my husband and I returned from our vacation, the laminate floor in the hallway of our apartment had swollen. My husband accused me of pouring water on it while cleaning it. I knew very well that it was not true. I even told him that. But he didn't believe me. Afterward, it turned out that a water pipe had burst during our vacation. I often have to justify myself for things I am not responsible for.” The therapist and the patient add four additional steps to the ‘self-regulation circle’ between steps 4 and 5: 4 A. “My husband or others, like my father in childhood, do not believe me. My thoughts and feelings don't matter. 4 B. My trauma film takes over: I feel I am nothing, and I am no good. 4 C. I become insecure and devalue myself. 4 D. I feel that I am being manipulated.” The patient knows the feeling of manipulation from her childhood. Her alcoholic father and mother had abused her narcissistically.

When working on the self-regulation circle, the therapist avoids any evaluation and strictly adheres to the conviction: ‘The patient's soul does nothing for free’. The more inappropriate the patient's thinking and feeling in the described conflict, the more likely it is an expression of a flashback. The therapist names the trauma as ‘trauma’ where applicable. He explores, together with the patient, the external stimulus that triggered the flashback. But then he does not continue exploring the trauma experience so as not to destabilize the patient further. Instead, he reinterprets the patient's self-protective behavior and denial in a consistently positive way. He refers to it as a ‘solution’ or ‘self-stabilization technique’ she has found herself, even if the solution seems ludicrous initially (see steps 17, 18, and 19 in case example 36 above). Working with the self-regulation circle strengthens the patient's cognition. It helps her observe and describe the content of her conflict from a meta-perspective, as well as internally assign her psychosomatic experiences on the table stage. The therapist, as an implicit doppelganger (see Sect. 2.5), stands shoulder to shoulder with the patient during the elaboration and mentalizes on her behalf if necessary. He helps her to name and differentiate her feelings. In doing so, he activates the patient's inner mentalization in her recurring conflict and facilitates her inner conflict processing. With the therapist's help, the patient learns to think of her recurring conflict in the as-if mode. This method helps patients feel more courageous when dealing with their recurrent conflict, more hopeful, and lively in their encounters. The mutual psychosomatic resonance warms the therapist’s heart.

Exercise 13

Create a self-regulation circle for one of your own recurring conflicts. Underline the personally meaningful statements and mark in red the actions for which you think: “But it can't stay that way!” You will notice: Until now, you have understood your problem in such a way that you are swaying between two opposing poles: “I'm not feeling well, now I'm fine again, now I'm not well again”. But the image of your self-regulation circle changes the internal development of your self-image in your conflict (see Sect. 2.4.1). You can see your participation in the emergence of your conflict and also in coping with it with greater clarity.

5.8 The Initiation of Trauma Therapy

Question

Why Moreno’s statement ‘Acting heals more than talking’ is important in psychodramatic trauma therapy?

The trauma-specific diagnosis, the crisis intervention, and the initiation of trauma therapy merge into one another. Trauma therapy is usually initiated due to a disruption or crisis in the therapeutic relationship (see Sect. 5.7) or in the patient's everyday life. Even a therapeutic conversation about a traumatic experience can exacerbate a patient's symptoms or trigger a flashback. This also applies to trauma-related disorders caused by trauma in childhood. For example, a 36-year-old patient in a psychosomatic clinic had a pseudo-epileptic seizure in the initial interview as he narrated his childhood experiences. He went into a trance state in which he ‘acted out’ his rape as a child in the children's home.

Central idea

The therapist struggles with a dilemma in trauma therapy. The patient asks her to treat his trauma-related disorder. However, as soon as the patient remembers his traumatic experience and talks about it, he often feels bad and slips into his flashback. His conflict processing freezes. Therefore, he cannot process his trauma experience through talking.

The therapist resolves the therapeutic dilemma in mentalization-oriented trauma therapy by letting the patient retrace the three metacognitive steps of dissociation in therapy in the as-if mode of play. Over time, the patient develops ego control over his dissociating (see Sect. 2.14). The therapist thus works also on his dysfunctional metacognitive processes that produce his dysfunctional cognition and makes them the subject of therapeutic communication.

• 1. She decides that she wants to understand the patient's symptoms as trauma-related.

• 2. As an implicit doppelganger and witness to the truth, she explains to the patient (see Sect. 5.5) that his symptoms are caused by a ‘trauma experience’.

• 3. In naming a relationship trauma from childhood, the therapist immediately places a second chair next to the patient representing his self-protection: “This chair represents your self-protection through self-stabilizing actions. As a child, you experienced that it is good to suppress your trauma memories and distract yourself.”

• 4. Then, the therapist places the third chair behind the chair for self-protection to represent the patient’s ‘traumatized child’. She places the puppet of a female or male child on this chair: “I understand that your depression is the symptom of a trauma-related disorder. You were traumatized as a child when you were hospitalized in an isolation room for eight months. The chair with the little puppet symbolizes you as the four-year-old child”.

• 5. The sight of his ‘inner traumatized ego’ or ‘traumatized child’ can trigger a flashback in the patient. The therapist, therefore, always asks the patient immediately after setting up the third chair: “When you see the emotionally hurt little boy on the chair over there, what emotions does it trigger in you?” The more severe the trauma and the stronger the patient's structural disturbance, the more likely he is to seek help from the therapist: “That scares me!” or: “I don’t like the child. I'm disgusted with him!” Such a reaction is a diagnostically valuable indication that the patient has a trauma-related disorder. Non-traumatized patients are more likely to answer: “The child makes me sad.” “I feel sorry for him.”

• 6. If the patient reacts with panic or disgust to his inner child, the therapist immediately grabs the chair representing the patient's ‘traumatized child’ and moves it to another place far away in the room.

Central idea

In this distancing technique, the therapist acts as a metacognitive doppelganger on the patient’s behalf (see Sect. 4.8) and follows her own inner impulses. This is because the patient has learned, as a child, to endure all events and pretend as if nothing happened. The inner masochistic self-censorship developed in childhood prevents him from willingly distancing himself from his traumatized ego. He doesn’t even know he can do that because he didn’t have enough help with his self-development as a child.

In doing this, the therapist informs the patient: “I'm going to place this chair at the other end of the room between the plants. You can see the little boy there. Is that ok?” The therapist makes a small bed with two towels for the ‘little boy’ on the chair and gently strokes his head once: “So, now he’s well looked after”.

• 7. The therapist asks the patient how he is feeling now. The patient mostly doesn’t understand this approach and is amazed. However, he feels physically ‘better again’.

• 8. The therapist sits down in her chair again. She checks whether, as the patient’s implicit doppelganger, she herself still feels paralyzed by the presence of his ‘traumatized child’ in the back of the room. If the therapist continues to feel blocked in her relationship with the patient, she carries the trauma chair out of the therapy room and through the door all the way out into the hallway and explains: “The chair for your traumatized self is still paralyzing me”. Afterward, she sits down in her chair again and observes whether her paralysis has now disappeared: “I feel better this way!”

• 9. Often the patient then takes a deep breath. It is only now that he notices the presence of his ‘traumatized child’ has paralyzed him too.

• 10. The therapist talks to the patient about how he felt when the third chair of his ‘traumatized child’ was still in the room.

• 11. She interprets the patient's bodily reactions at the sight of his ‘traumatized child’ as the ‘beginning of a flashback’. She informs the patient about the definitions of psychological trauma and flashback: “You want to think, feel and act differently in the flashback. But you can't because you feel existentially threatened.”

• 12. The therapist practices a self-stabilization technique with the patient if necessary.

• 13. She plans the subsequent steps in trauma therapy together with the patient.

The patient sometimes understands the statement, “You are traumatized”, in equivalence mode: “The therapist cannot tolerate me being insecure or weak.” Therefore, the therapist does not ask the patient: “Could it be that you are traumatized”. Instead, she marks it as a real finding: “You are traumatized.” And immediately represents the patient’s “traumatized ego” with a chair next to him. As a result, the patient also represents his ‘traumatized ego’ internally separately from his self-image in the relationship with the therapist. The external distance to the second chair for his ‘traumatized ego’ helps him to distance himself from it internally as well.

Patients who were only traumatized in adulthood usually do not have a developed defense system against the intrusion of their trauma film. They dissociate even with the smallest of external triggers or feelings of insecurity, feelings of being at someone’s mercy, and helplessness (see Sect. 5.2).

Central idea

According to Wurmser (1998, p. 425 f.), dissociating is a form of “split between the observing ego and the acting ego... This split includes a massive denial of the overwhelming feelings.” Psychodramatic dissociating helps the patient retrace his defensive dissociating as a creative process in the as-if mode of play and bring it under his ego's control.

The therapist’s approach to adult post-traumatic stress disorder is slightly different than to childhood relationship trauma. It is similar to the therapy approach used for anxiety disorder with real justified fear (see Sect. 6.2):

• 1. She addresses the trauma as a witness to the truth. However, she does not represent a defense system because this is not yet developed.

• 2. The therapist immediately places a second chair next to him for his ‘bad feelings’, ‘trauma’, or ‘traumatized ego’. She thus carries out the inner ‘split between the observing ego and the acting ego’ outside on the stage in the as-if mode of play.

• 3. The patient usually perceives his ‘traumatized ego’ as much too close. He is drawn into the trauma experience. Therefore, the therapist takes the second chair representing his ‘traumatized ego’ and places it far away in the corner of the therapy room or in front of the door. It is good for the patient when he can no longer see his ‘traumatized self’. Putting away the trauma chair is a distancing technique similar to the safe vault technique. It dissolves the patient's panic a little and stabilizes his soul.

• 4. The therapist asks the patient what works well for them at home if they are troubled by trauma memories. Then, she asks him to make a written list of these actions and refers to them as ‘self-discovered self-stabilization techniques’. If necessary, she adds to this list and practices further self-stabilization techniques with him (see Sects. 5.9 and 6.2).

Exercise 14

You cannot understand metacognitive therapy just by reading about it. Therefore, try acting psychosomatically in a role-play with a colleague. Explore how it feels to confront a patient with a diagnosis of ‘trauma-related disorder’. Use two different versions: In the first part of the exercise, you inform the ‘patient’ about his trauma-related disorder and his recurrent flashback, face to face, without using the second chair. You will find out: In his role as the patient without the second chair, your colleague feels devalued and like he has become an object of observation. In the second part of the exercise, when confronting him, you place a second chair next to him to represent the ‘traumatized ego’ of the ‘patient’. You look at this chair shoulder to shoulder with your ‘patient’. Then, as described above, you act as a metacognitive doppelganger and move the second chair further away on his behalf.

You will notice: When confronted with his trauma, your colleague feels more comfortable in his role as the ‘patient’ with the trauma chair next to him because he looks at his ‘traumatized ego’ as a chair from the meta-perspective. But, the two-chair technique is also good for you as a therapist. In the interaction with the patient, as an implicit doppelganger, you internally develop two different empathy processes alongside one another. On the one hand, you identify with the patient's ‘traumatized ego’ and feel his fear yourself. On the other hand, you identify with the “patient” in the role of his observer and stabilize him as a doppelganger in the meta-position.

The therapist uses the two-chair technique in group therapy as well.

Case example 37

At the end of a group therapy session, a 45-year-old distressed woman shares: “Somehow, I'm standing by my side. Today I wanted to practice not feeling ashamed anymore when I have to show myself. But now I feel bad!” The therapist senses a latent panic in the patient. He takes an empty chair and places it next to her: “You say you're standing by your side. So you are standing next to Margrit, who thinks as a healthy adult, that you are otherwise. I am therefore placing this chair next to you to represent the healthy adult Margrit. I suspect you got caught in a trauma film when you forced yourself to confront your shame. Please move to this other chair of your healthy adult thinking!” The patient sits down on the other chair. The therapist: “If you don't want to show yourself, it's not your neurotic inhibition. I believe hiding your inner world from others is an old form of self-protection. It has helped you avoid existential threats in the past.” The patient confirms the existential quality of her fear. She feels relieved. The radically positive revaluation of fear as a form of self-protection in a trauma experience stabilized her.

The therapist can also use the table stage for an initial trauma-specific consultation. As with crisis intervention (see Sect. 8.8), the therapist symbolizes the temporal sequence of the patient’s crisis as a timeline, with one stone for the beginning and another for the present. Then, together with the patient, she represents his ego with three stones on the table, one for his ‘competent ego’, one for his ‘traumatized ego’, and one for his ‘self-protection through adaptation or grandiosity’. Furthermore, they represent the people involved, the patient’s feelings and ideas, the institutions involved, and the relevant objects with stones and wooden blocks. In doing so, the therapist helps the patient create his soul landscape.

The therapist explains to the patient the definition of dissociating in a psychodramatic symbolic act: She touches the stone for his ‘competent ego’ with one finger: “This stone represents your healthy adult thinking.” She takes this stone from the table stage and puts it under the table on the floor: “If you have a flashback, you internally change from your healthy adult thinking into your traumatized ego.” The therapist points her hand to the other stone representing his ‘traumatized ego’ on the table: “You only feel inferior in the trauma film. Your thinking is blocked. Nothing works anymore. In psychotherapy, we call this a flashback! Both your traumatized ego and competent ego appear in you one after the other. In therapy, you can learn to notice when you have a flashback and when you think as a healthy adult in therapy.” The therapist touches the third ego stone on the table: “This stone represents your self-protection through hiding and your self-stabilizing actions.”

Recommendation

The therapist can give ego-strong patients the stones for their ‘competent ego’ and ‘traumatized ego’ to take home with them: “Put these stones in your pocket or put them on your desk at home. Look at these stones once a day. If you can't tolerate the sight of your ‘traumatized ego’, take the stone to the cellar and lock it in a cupboard!” In this way, the patient represents the external separation of his trauma-related psychosomatic resonance pattern from his inner self-image here and now in his memory centers. The patient needs 6–12 months to neuronally rewire this disconnect in memory. The trauma experience is no longer stored under the term “I am inferior”, but under the new term “I am traumatized”.

Case example 38

The 38-year-old Ms. C., traumatized in childhood, travels 300 km for a crisis discussion with the therapist. She complains: “For the first time, I feel I am in the right place at my job. But my employment contract is limited to one year. It expires in four weeks. I should speak to my boss. But I'm scared because my boss is very insecure and unreliable. If I tell him I want a new employment contract, he'll terminate me immediately!” The therapist invites Ms. C. to present her concerns to the ‘boss’ through role reversal in a fictional psychodramatic dialogue. It turns out that her boss does seem to be a problematic person. In the fictional dialogue, Ms. C. reacts increasingly insecurely and aggressively toward her boss’s behavior and ‘forgets’ what she wants. The therapist asks her: “Do you notice this in other relationships that you become so chaotic and aggressive when someone behaves in an unreliable manner toward you?” Ms. C.: “My boss is exactly like my mother. With her, what is right today was wrong the next day! If the wooden board is supposed to be in the sink in the evening, it shouldn't be in the sink in the morning. Whenever I reminded her of her task, she simply denied everything: ‘I never said you must have been imaging things.’”.

The therapist fetches two finger puppets from a cupboard and suggests: “Please choose two finger puppets or two Playmobil toys. The puppets should be small enough for you to hold them in your hand. One puppet should symbolize you as an adult, and the other should represent your child ego. You say you want to meet your boss about your employment contract. Then put the child puppet in your right and the adult puppet in your left pocket. As you stand on your boss's doorstep, speak to your child puppet internally as the adult you are: ‘Yes, I know that you are scared and confused. You're right, the boss is stupid! But now the point is that, as an adult, I must preserve my interests and achieve my goal! Otherwise, we will soon have no more money to buy food. I'll comfort you when the conversation is over!’ Then go into your boss's room and tell him what you want to say as an adult!” Ms. C. goes home after the therapy session.

Six months later, Ms. C. gratefully told the therapist: “I was able to talk to my boss then, and it went well! I even had the puppet in my hand. That helped me a lot! But it was good that I also had the puppet for my competent ego with me! At one point, the puppet representing my traumatized child threatened me. But then I was able to hold on to the puppet for my competent ego.” The external presence of the finger puppets allowed the patient to internally delegate her flashback to the finger puppet of her ‘traumatized child’. This enabled her to think and act as a healthy adult in a situation that would otherwise have triggered a flashback.

Central idea

The ‘inner traumatized child’ should potentially develop into a ‘healthy inner child’. Then, it can advise the patient if they are needy. The ‘inner child’ thus becomes a symbol of the patient’s true self. The therapist supports this development with a psychodramatic dialogue (see Sect. 8.4.2) between the adult ego and the child ego (see Sect. 4.10). At the end of the therapy, the therapist can diagnose the extent of the treatment’s success from the quality of the patient's interactions with his ‘inner child’.

The external representation of the flashback as a stone or a puppet is a distancing technique. Traumatized patients can use this technique if they feel agitated at night or have severe sleep disorders. They carry the puppet, which represents their traumatized child, from their bedroom into their living room at night. They make a small bed for the puppet in a closet and tuck it in. They go back to their bedroom and try to sleep there. Distancing techniques are techniques for self-stabilization. For example, the patient can symbolize his trauma with an object and lock it in a cupboard in the basement or bury it in the ground in the garden or the forest. This method is similar to the safe vault technique. The therapist asks the patient to imagine a safe vault in a place only accessible to him. Only the patient has a key to the safe. In his inner imagination, he goes to the safe with the ‘trauma’ symbolized as an object. He opens it with his key and puts his ‘trauma’ inside. He locks the safe again and hides the key in a place only he knows. Then he returns from his imagination to reality. Distancing techniques improve one’s mental state in a crisis. However, the relief usually only lasts for a few hours or days. Psychodramatists help their patients perform the distancing techniques not only in their imagination but also in a sensorimotor way. External physical distancing in the as-if mode of play actualizes other internal images via the psychosomatic resonance circuit between the memory centers of sensorimotor interaction patterns, physical sensations, affect, linguistic concepts, and thoughts (see Sect. 2.7). The patient internally feels more confident when the ‘trauma’ has been distanced externally.

5.9 Self-Stabilization and Associated Techniques

Reddemann (1999, oral communication) says: “Trauma therapy is self-stabilization, self-stabilization, and nothing but self-stabilization! Many trauma patients do not go beyond the self-stabilization phase in their psychotherapy. But they still benefit from their therapy.” The following trauma processing (see Sect. 5.10) requires that the patient has previously learned techniques of self-stabilization and can apply them.

Important definition

In a flashback, patients think in equivalence mode and experience the current situation as if the trauma happened in the here and now. Self-stabilization techniques help the patient to activate helpful psychosomatic resonance patterns within themselves. Unlike in a flashback, these techniques enable the patient to internally think and act in the as-if mode in the current situation. The ability to act internally in the as-if mode is crucial in mastering life. It is also the prerequisite for trauma processing (see Sect. 5.10).

The self-stabilization work should always be related to the “traumatized ego” symbolized by another chair. Over time, many traumatized people autonomously find specific techniques to stabilize themselves. “In fact, it was through our patients that we first came across these possibilities of creating an inner safe place or helpful beings” (Reddemann, 1999, p. 90). In the flashback, the patient once again experiences the existential distress of the traumatizing event. Therefore, anything that helps patients get out of the dissociative state of consciousness is good. Some signs that would be a symptom in people with neurotic disorders can be positively reevaluated as ‘a self-discovered self-stabilization technique’ in traumatized patients.

Central idea

Burge (2000, p. 315) believes that sometimes even antisocial behavior has to be interpreted as a measure for self-stabilization in trauma therapy, for example, withdrawal from relationships. Exaggerated fearfulness and a great need for control can be understood as an attempt to act differently as compared to during the trauma event as a precaution. In doing so, the affected person tries not to lose track of things, at least in the current situation. The patient protects himself and others from feelings of helplessness and the threat that reminds him of his trauma.

Many patients simply distract themselves when they feel bad. For example, they play games on the computer or sit in front of the television. The therapist might see this as critical for other patients doing the same. Reading books can also stabilize the soul. A patient with relationship trauma in childhood was terrorized by her traumatized father. But in the evening, she always read novels about the daughter of a forester named ‘Pukki’ in bed. She stabilized herself through her identification with ‘Pukki´s experiences. The good always triumphed over the bad in these novels. Many patients with trauma-related disorders play sports, which is sometimes even addictive. Sports activities are essential to trauma therapy because physical activities also stabilize the soul. Working is also a self-stabilizing technique because the patient has to concentrate on the subject of his work, which distracts him. He forges social relationships at his workplace. He knows what is wrong and what is right in his work. He receives recognition, thereby improving his self-esteem. The money he earns makes him independent.

Case example 39

A 55-year-old teacher sought therapy because of exhaustion and migraines. In her childhood, she was ‘not wanted’ by her parents and grew up in a broken family. When she was seven, she saw her teacher mistreating other students at school. She then decided, “One day, I'll be a good teacher!” And she did. In old age, however, she lost the strength to live up to her own grandiose ideals in her work. She couldn't tolerate being just a ‘normal’ teacher for her students. She got engulfed in a grave trauma-related identity crisis.

People traumatized in childhood often develop trauma-related anxiety and depression after the end of their professional life. Because excessive work protects traumatized people from allowing their feelings to surface and becoming dependent on others. In 2004, Radebold (2004, pp. 33, 41) found that 20% of those over 60 years old in Germany suffered from depression and anxiety. In other countries, however, it was ‘only’ 10% of those over 60 years. These older adults were traumatized as children by experiences during the Second World War, for example, when they were fleeing, during a bombing, or when they lost close relatives. “They had ‘no noticeable symptoms’ in their working life before the age of 60 […]; all through their life they functioned inconspicuously and some even well enough due to the specification of the tasks delegated to them” (Radebold, 2004, p. 12). However, if these people were to lose a close caregiver to death in old age or if they themselves became sick, helpless, and dependent, it would easily trigger their traumatic experiences from childhood, and they will be retraumatized (Kellermann, 2009, p. 30f.)

Central idea

Some people can process a traumatizing experience adequately well (see Sect. 5.13). They get to a deeper, transpersonal level of feeling and thinking without therapy. After encountering death or the absurd, those affected feel unexpectedly at home in something super-personal and experience a new transpersonal connection with something larger.

For example, they are ‘wonderfully protected by good forces […]’ (Bonhoeffer 1944). This experience does not occur on the level of well-being and wellness. It opens the door to something new, essential, a new expanded identity, one's own ‘inner being’ (Dürckheim, 1984, p. 39 f., 168, 1985, only oral communicated). Such a step in development makes some affected people human and wise in new ways. The potentially traumatic experience leads to ‘post-traumatic growth’ (Fooken, 2009, p. 65 ff.).

Central idea

Traumatizing experiences lead those affected into basic human fears (Dürckheim, 1995, only oral communicated). They open the existential level. Going through a basic fear can become a transpersonal experience.

Going through the fear of death can give rise to a feeling of a great, comprehensive life. Going through absolute loneliness can give rise to all-embracing love in the affected person. Going through the fear of madness can result in an experience of all-encompassing sense. Going through the fear of absolute emptiness may eventually result in one experiencing the abundance of being. According to Dürckheim (1995, oral communication), transpersonal experiences can occur in the areas of nature, art, love, or religion. If possible, trauma therapy should also include the existential or spiritual level of the soul. Trauma patients would often search autonomously for transpersonal experiences to self-stabilize themselves. But they seldom gave them the appropriate meaning. The therapist must, therefore, actively seek such a transpersonal experience in her patient’s life. She acknowledges this experience as ‘existential’ or ‘in the broader sense as spiritual’. The patient should learn to use such an experience as a resource for his soul. That improves his chances of recovery.

Case example 32 (2nd continuation, see Sects. 5.1 and 5.2)

Mr. A., traumatized in the hospital at the age of four, withdrew from all relationships throughout his childhood and adolescence. He built treehouses in the forest with the wood waste from a nearby carpentry company. The treehouses were a shelter and, at the same time, a ‘safe place’ for him (see Sect. 5.10.5). As a child and adolescent, he often wandered alone through the fields and the forests and observed the animals. He often sat alone by a small lake surrounded by forest all around. He was just there, becoming one with nature. Nobody wanted anything from him.

Case example 40

A 40-year-old patient grew up in a family characterized by physical and sexual violence. Even as a child, he often fled secretly into the forest at night. He screamed in the dark, just like the ravens he heard in the forest. He became so one with nature. As part of his therapy, he wrote a fairy tale of coping (see Sect. 5.14): In it, the teacher noticed during his primary school days that “little Karl was always unfocused at school. So she visited his family at home. There she discovered his mother's bruises. His father had abused his mother. The teacher informed the youth welfare office. In the fairy tale of coping, little Karl was placed into a caring foster family with his sister.” Unfortunately, this tale's healing effect disappeared again after a few weeks. The patient felt: “Over time, the little boy in the fairy tale of coping became suspicious of his foster parents. He couldn't believe that the foster parents really loved him.” Therefore, the patient had to expand his coping fairy tale: “The little boy would leave the foster parent's house at night if necessary and go into the woods to a raven tree. He would climb the tree and enter a hallway through a door inside the tree. When the ravens came flying in, they would go in through the door and turn into people. When the little boy came, the Ravens would always greet him warmly as a member of their clan. There were six doors in the large hallway in the raven tree. These led to different rooms, one to play in, another to sleep in, and another to eat in, etc. The boy always went into the room he needed. He would return to his foster family during the day.” For several years, the patient kept inventing new episodes in his fictional life with the foster family, if necessary. The world of ravens would help stabilize himself. He experienced: “I can reach into the depths. My soul comes alive. I am no longer dependent on others” (continued in Sect. 5.14).

Case example 41

A woman with relationship trauma was ‘not wanted’ by her parents as a child and did not get a good enough response to her own existence from her family. She found the desired response in religious contexts: As a five-year-old girl, she often went to church alone. She sat down in front of the altar and prayed to God. As an adult, she explained to the therapist: “I had someone to talk to there”.

Case example 21 (see Sect. 4.6, continued)

A patient whose mother had narcissistically abused him had built a dollhouse in his childhood against massive opposition from his mother. At the end of therapy, he used this creation for self-stabilization. Whenever he found himself drowning in his feelings of senselessness again, he would put the dollhouse on his lap and play with it. He regained access to his internal feelings and desires through external acting and playing with his dollhouse. The patient described his dollhouse as his ‘magic box’.

In the phase of self-stabilization, the therapist and the patient first look for existing actions the patient has developed autonomously to make him feel better. The patient himself often evaluates these behaviors as “crazy, you shouldn't act like that”. However, the therapist re-evaluates these neurotic actions radically positively and explicitly names them “self-stabilization techniques”. She represents each of these actions with a rock or block of wood on a second chair symbolizing the patient's self-protection. These actions result from the defense through grandiosity, perfectionism, control, or adaptation to the expectations of the community (see Sects. 4.7 and 4.8). In this way, the therapist gives the patient's “existing self-stabilization techniques” appropriate meaning. The patient should write down the self-stabilization techniques on a piece of paper and number them. He can read this list at home when needed. Even reading the list is a self-stabilizing technique. This clears up the fog in the patient’s head as he realizes he can do something about suffering a flashback.

Central idea

The patient acts out his autonomously developed self-stabilizing actions in equivalence mode because he cannot but do so. However, he now makes neuronal links between the sensorimotor interaction patterns, physical sensations, affect, and thoughts of these actions, and the linguistic concept of ‘self-stabilization’ in his memory. Thus, they are available to him in the as-if mode of thinking. The patient can consciously use them when needed.

The therapist also teaches patients other self-stabilization techniques as needed:

• 1. When patients dissociate, they often involuntarily revert to the posture, facial expressions, and gestures they had during the original trauma event. The therapist, therefore, encourages the patient: “Please concentrate on what you see in the room here and now! What do you feel in your body right now? What do you smell? What do you hear? Stretch your limbs, and now change your breathing. Correct your posture. Assume a posture that is familiar to you in situations of wellbeing, joy, or sporty competitions” (Christine Rost, 2013, only oral communicated). The sensorimotor activity involved in this exercise often helps the patient astonishingly quickly to return to healthy adult thinking.

• 2. The ‘safe place’ self-stabilization technique is described in Sect. 5.10.5. It leads the patient into a complex, individually designed, fictional experiential space where he can stabilize himself by acting. Some elements of the ‘safe place’ technique are also known individually as self-stabilization techniques, for example, the introduction of inner helpers or fictional, good parents (Grimmer, 2013, p. 194 f.).

• 3. A helpful fictional interacting doppelganger enters the protagonist’s play of the traumatizing situation and helps the patient to protect himself from disintegration through surplus reality. He banishes the perpetrator, creates a shelter, or helps the protagonist escape. In this way, he gives support to the protagonist’s self. Integrating such a stabilizing experience into the trauma memory in the as-if mode of play differentiates and expands the capacity to cope with the trauma (Kellermann, 2000, p. 31). It helps the patient to reassure himself emotionally that his trauma has and is allowed to have great significance for him and that he is allowed to feel what he is feeling (Kellermann, 2000, p. 27 f.). The doppelganger technique has been part of the standard repertoire of therapy for people with trauma-related disorders in psychodrama since Moreno.

Case example 42

A 26-year-old student, Ms. E., was traumatized by a hospital stay in her second year of life. She repeatedly shared with fear in group therapy: “I do not want to imagine that my mother or father will die one day. I can’t even think about it!” The therapist offers the patient: “Would you like to tell your mother through a protagonist-centered play that you are terribly afraid of her death?” Ms. E. engages in a fictional psychodramatic dialogue with her ‘mother’. In doing this, she steps into the role of the mother through role reversal and replies as the mother: “But I too will die at some point. That's the way it is!” This sentence triggers panic in Ms. E. again. At first, she understands her fear ‘only’ as panic about the inevitability of death.

The therapist: “What scares you most about your mother's statement?” Ms. E., in a low voice: “Then I'll be alone!” The therapist: “You are afraid of being alone!” Ms. E: “Yes!” The therapist wonders: “And it doesn't help you feel less scared if you think about your boyfriend and getting married soon!” Ms. E.: “No.” The therapist: “Was there a time when you felt lonely as a child, and your mother and father were not available to you?” Ms. E. ponders: “Not really!” But then she remembers: “My mother once told me I had to be in the hospital for three weeks due to pneumonia when I was two years old. It was a matter of life and death for me. My mother said: ‘When I visited you in the hospital, you always turned your face away from me and looked at the wall.’ As a result, my mother felt very insecure. She no longer knew whether I even loved her as a child.”

The adult student plays the story told by the mother. As a one-and-a-half-year-old girl, she is seriously ill ‘in the hospital bed’. When the ‘mother’ visits, she turns away and turns her back on her. Two group members play the roles of the ‘mother’ and the ‘father’. However, they spontaneously act differently than the mother in the original story. They speak to little Sabine and caress her back. They don't stop showing her their gentle love and affection. Until the end of the play, the protagonist lies motionless in her ‘bed’ with her face to the wall, without crying. After the play, the therapist asks the patient for role feedback. Ms. E. is happy and relieved: “That was so nice! Although I didn't turn around, I felt your love and affection as my parents! But the most important thing was: I noticed how much I love my mother. I love her a lot! My mother told me this story so differently. That's why I've always doubted whether I love her. But that's not true at all!” Tragically, the patient's mother fell ill with cancer six months later and died. But Ms. E could accompany her in a good way as she died without decompensating again because she was now sure that she had always loved her mother.

• 4. The patient can also use imaginative techniques for self-stabilization. For example, he writes a fairy tale of coping (Krüger, 2013). Or he alleviates his nightmares with Imagery Rehearsal Therapy (Krakow, Kellner, Pathak, Lambert, 1995). Or he consciously develops a positive counter-image to his negative emotions (Reddemann, 1999, p. 90). I describe these techniques in Sect. 5.14.

5.10 Trauma Processing

5.10.1 Processing Trauma Experience Through Acting into a Coherent Story

Usually, “when people absorb information […], they automatically synthesize it […] with their prior knowledge. If the event has personal significance, then they rewrite these feelings into a story without being aware of this process of rewriting […]” (van der Kolk et al., 1998, p. 72). The story's logic and meaning then determine the significance of the individual elements of the story for conflict resolution. The unimportant elements can get lost in the neuronal interconnections of the memory. This saves memory space in the brain. The core pathology in people with trauma, however, is dissociating.

Central idea

Dissociating results in the trauma event remaining “stored in the form of isolated images, somatic sensations, smells, and sounds […]. [...] Apparently, the integrative functions fail, such that the spatial and temporal allocation of incoming information is disturbed” (van der Kolk et al., 1998, p. 72). Traumatized people cannot synthesize their trauma memories with previous knowledge or categorize them and rewrite them in a personal story that integrates the memory fragments and gives them meaning in the larger context.

In the case of trauma, for example, unfinished movements are frozen in the body's memory. If the patient had stepped on the brakes before his car accident, the panic from back then resurfaces with the same leg movement in similar situations. Sometimes the affected person also experiences intense feelings but cannot remember the associated event. In the event of a trauma, the individual sensorimotor interaction pattern, physical sensations, and affect remain unaltered in memory as fragments. The shock freezes one’s conflict processing ability. The fragments are not integrated into a story. However, because of their high energy potential, they re-enter the present experience even with small triggers. The affected person then experiences the traumatizing event in the equivalence mode (see Sect. 2.6) as if it happened in the here and now. Naming linguistic terms and thinking is hardly or not at all available during a flashback. The language center in the left hemisphere is not or not sufficiently activated. The patient cannot understand his seemingly meaningless psychosomatic reaction. He is insecure and has doubts about himself. As a consequence, he secondarily suffers from masochistic low self-esteem and depression. The incoherent feelings and physical reactions make it difficult to cope with everyday life and trap one’s energy. Therefore, trauma processing begins with patients narrating the trauma event repeatedly (Kellermann, 2000, p. 28). “A person must integrate the cognition, emotions, bodily experience, and actions of a traumatic experience for processing or synthesizing it” (Reddemann, 1997, p. 666).

Central idea

In trauma processing, the patient should further develop his trauma memory into a holistic trauma history. To do this, the patient must integrate his sensorimotor interaction patterns, physical sensations, and affect in his trauma experience with appropriate linguistic concepts, and thoughts (see Sect. 2.7) into a holistic psychosomatic resonance pattern and link this appropriately with other memories.

The indication for the type of trauma processing depends on the therapy goal. If a patient only remembers a few parts of his trauma story, the therapist can have the patient use the screen or video technique to develop the existing puzzle pieces into a coherent fictional story. In doing so, the patient takes on the role of his ‘observing ego’ and sees his ‘acting ego’ in action from outside ‘on a screen in a film’. He thus integrates all his memory fragments into a subjectively coherent, holistic story. The story gives the individual memory fragments an appropriate meaning in a superordinate context. The feeling of meaninglessness disappears.

Case example 43

A 48-year-old patient with bulimia (F50.2) kept talking about an event from when she was five years old. At the time, she had come home from shopping and was completely confused for three days. Her concerned parents asked her about it. As a five-year-old, she could only tell her parents something about a ‘red car’. It was unclear what had happened to her then. The therapist made an appointment with the patient to develop the event into a coherent, holistic story. He sat down with the patient in front of a fictional screen. The therapist and the patient let the events from when the patient was five unfold in front of them as a film per the video technique. The patient held the remote control for the ‘video player’ in her hand and let the imaginary ‘film’ begin. She let it run forward or pressed rewind in some places. With the therapist's help, she determined what had happened back then: the five-year-old girl goes through the village on her way to the butcher. A red car stops next to her on the road. The driver is a middle-aged man. He offers to give her a lift to the city center. She doesn't want to go at first. But then she gets in hesitantly. The man doesn't stop the car at the butcher's. He drives her out of town on a country road. He pulls the girl out of the car and pushes her down onto the embankment. He strips in front of her and forces her to give him oral pleasure. He then threatens the girl: “Don’t you dare tell anyone about this. If you do, I'll come and hurt you!” Then he drives away and leaves her stranded. The girl goes home completely distraught. The parents notice that something is amiss with the girl. They ask her very affectionately and treat her with care. But the girl can't tell the parents anything. According to the imaginary story, the perpetrator represents the vacuum cleaners. He drives away to a city 40 km away. He lives there as a family man with his wife and two children.

In other patients with trauma-related disorders, talking and imagining alone is not enough.

Central idea

Van der Kolk et al. (1996, p.195) think: “With their propensity to act and their lack of words, these patients can often express their inner states more clearly through physical movements or images. Painting and psychodrama can help them develop a language essential for effective communication and the symbolization that occurs in psychotherapy.”

Traumatized patients, in particular, affirm Moreno's sentence, which is otherwise only valid with restrictions (Krüger, 1997, p. 71): “Acting is more healing than talking” (Pörtner, 1972, quoted from Leutz, 1974, p. 145). For example, the patient Jill reports in the case example by Karp (2000, p. 77 f.): “In the hospital, I had two sessions per week, but it… was a recitation with more pills. The reality was not there. It was like telling a story, whereas, in psychodrama, you relive it.… In reliving it, you go through the emotions; otherwise, it's just like reading out of a book. It doesn't have the same impact.… But when you are re-enacting it, you have to be in control because you have to say: ‘All right, if I had a choice, this is what I would have done’”. Patient Maria in the case example by Roine (2000, p. 86) has similar views: “I… went to a psychologist for many years. I talked and talked but never got behind the words and into my feelings, not because I didn't want to, but because, as a child, I had learned well how to escape from my feelings and how to disappear inside myself to avoid facing reality”.

5.10.2 The Four Functional Workspaces for Trauma Processing

According to van der Kolk (1995), it is the ‘nature of trauma’ to be dissociative. The dilemma in trauma therapy is that: trauma patients must go through dissociating to process their trauma. If the patient goes through dissociating, however, his conflict processing freezes.

Central idea

A patient experienced ‘nothing new’ during a two-hour psychodramatic re-enactment of the trauma event (see case example 14 in Sect. 2.12.2). This was because she dissociated and split off his sensorimotor interaction patterns, physical sensations, and affect. The usual psychodramatic re-enactment of a traumatic event is often not therapeutically sufficient.

Dissociation (see Sect. 5.4) is a dysfunctional metacognitive process involving four consecutive steps:

• 1. When a patient dissociates, he unconsciously splits his ego into observing ego and acting ego. He goes inwards into his observing ego, and functions externally at the level of words and thought, but stops the inner perception of his physical sensations and the panic in his acting ego. This creates the feeling of depersonalization. He then stands beside himself. He experiences everything as ‘unreal’ or ‘like in a film’.

• 2. The patient stabilizes himself by denying his traumatic experience. He pretends nothing has happened: “What’s in the past is past. I'm looking ahead!” In this way, he remains more or less able to act in his current life.

• 3. The patient stabilizes the denial of his traumatic experience with a compensatory counter-fantasy (Mentzos, 2011, p. 39). In the case of childhood trauma, this develops into compensatory reaction formation over time. For example, the patient gives meaning to his life by taking on a role as a helper or member of a sect-like community.

• 4. Reaction formation is secured by a precautionary or exaggerated need for control and by ideological rationalizations (see Sect. 4.7). Excessive control helps the patient avoid situations of helplessness that could trigger his flashback. For example, as a 40-year-old mother, a patient would control her eight- and twelve-year-old children with excessive anxiety and constraint. She herself was traumatized as a young political prisoner in Poland. Any possible danger to her children triggered a flashback in her. She couldn't bear to imagine that her children might be at the mercy of a threat.

Central idea

A traumatized patient, when dissociating, perceives his external world in the equivalence mode (see Sect. 2.6), as if the traumatizing situation from the past was happening now. He does not differentiate between the internal flashback and the present external reality. He is in a state of ego confusion.

Recommendation

In metacognitive trauma processing, the therapist represents the four steps of the dissociation process as different workspaces with chairs externally in the therapy room and names them (Krüger, 2002, p. 133 ff.). The patient thus perceives the four metacognitive workspaces in the as-if mode of play. He learns to represent them internally in the as-if mode of thinking and to distinguish between them consciously. The defensive dissociation is resolved by the psychodramatic re-enacting of the dissociation process.

The therapist takes the following steps in doing so:

• 1. The split between the acting and observing ego is realized by setting up a second chair for the ‘traumatized ego’. The patient then sits on the chair of his healthy adult thinking and looks at the second chair representing his “acting ego”. The chair of the ‘acting ego’ symbolizes the interaction space between himself as the victim and the perpetrator (see Fig. 5.2).

  Fig. 5.2

  

  The four work rooms for disorder-specific psychodramatic trauma therapy

• 2. The chair for healthy adult thinking represents the patient’s observing ego and the narration and observation space. The patient looks, from the observation room, at his ‘acting ego’ in the interaction space and sees himself as a ‘victim’ in interaction with the ‘perpetrator’. In this way, he forms a relationship with his ‘acting ego’ and resolves his defense through denial. He no longer pretends as if nothing has happened.

• 3. In the case of childhood trauma, the therapist places the third chair next to the patient for self-protection through grandiosity, perfectionism, or adaption. This realizes the compensatory counter-fantasies and self-stabilization techniques spontaneously developed by the child to master his life. Together with the patient, the therapist records his distinct ways of denial and explicitly names them ‘self-stabilization techniques’. In doing so, the patient develops ego control over his defense through denial. He learns to use his denial in the service of the ego. If needed, the therapist supplements the patient’s compensatory counter-fantasy, for example, by setting up the ‘safe place’ (see Sect. 5.10.5).

• 4. The therapist psychodramatically transforms the patient’s need for control into an information and control space. The therapist and the patient define the terms ‘traumatizing situation’ and ‘flashback’ from the meta-position of his trauma scene (see Fig. 5.2). Traumatized patients had no opportunity to influence and change their traumatizing situation. The therapist, therefore, informs the patient in detail about her therapy plan. She asks for his consent on how to process the therapy, for example, how the traumatizing situation should be rewritten and completed in the re-enactment.

Psychologically healthy people are internally flexible and consistent in switching back and forth between these four inner metacognitive workspaces when processing their conflicts. In this way, they maintain coherence in their internal process of self-development in the external situation. However, when dissociating, traumatized people are stuck in one of the metacognitive processes and live it out in the equivalence mode. Therefore, during trauma processing, the therapist lets the patient move to the various metacognitive working spaces and re-enact them in the as-if mode. In doing so, the patient further differentiates each working process in relation to the traumatizing situation in the as-if mode of play. In doing so, the patient develops a holistic psychosomatic resonance pattern for his trauma event (see Fig. 2.9 in Sect. 2.8) and gains ego control over his dissociation during trauma processing.

Exercise 15

You can understand the meaning of the four workspaces of trauma therapy only when you psychosomatically act in them in the as-if mode of play. As an implicit doppelganger, accompany one of your traumatized patients in the as-if mode of play through the four different trauma therapy workspaces (see Fig. 5.2 above) in your therapy room: (1) To do this, divide your room into four work rooms with a rope, as shown in Fig. 5.2. (2) Place two empty chairs facing each other in the interaction room, one for the patient and one for their perpetrator or the traumatizing event. (3) Set up another chair for your patient in the narration and observation room with a view of their trauma event. (4) In the third quadrant of the circle, set up a chair for the patient’s role in their safe place. (5) Then, sit down in the information and control room. Place a second chair in front of you. Imagine that your ‘patient’ is sitting across from you in that chair. Let your ‘patient’ move back and forth between these four work rooms in your imagination. What would your patient do in each of these rooms?

Central idea

The concept of the four work spaces gives the therapist support and orientation in her practical work with traumatized people. She notices in which ‘work room’ she is currently present with her patient. She realizes which therapeutic options she may have neglected so far.

The therapist can use the concept of four work rooms for trauma processing in three different settings: (1) in psychodramatic trauma processing with the help of auxiliary therapists in individual therapy (see Sect. 5.10.3), (2) in psychodramatic trauma processing with the help of the table stage in the individual therapy (see Sect. 5.10.10) and (3) in psychodramatic trauma processing in group therapy (see Sect. 5.10.11).

5.10.3 Trauma Processing with the Help of Auxiliary Therapists

The psychodramatic trauma processing with the help of auxiliary therapists takes place as follows:

• 1. Traumatized patients, by definition, had no control over the traumatizing situation. They are, therefore, afraid of processing the trauma, even if they have decided to do so. Therefore, the therapist and the patient collaborate and plan the trauma processing approach step by step: Together, they choose a specific trauma event. They agree on what should and should not be done when processing the trauma. During the planning phase, the therapist informs the patient about the four work spaces for trauma processing. She defines the chairs on which they both sit as the ‘information and control room’. She also sets up three other chairs on the stage, one for each of the three other work spaces. She moves with the patient from one work room to the other and explains how the patient can use the respective work room during trauma processing. Then the therapist and the patient sit back on the chairs in the information and control room.

• 2. In three to six individual sessions, the patient learns the self-stabilization techniques required for processing trauma in any situation, including the patient's ‘safe place’ (see Sect. 5.10.5).

• 3. The therapist and the patient determine what the patient needs when re-enacting the trauma situation so that what did not happen then happens now or what happened then does not happen now.

• 4. They plan the timing of the actual trauma exposure session and determine which auxiliary egos and objects will be required.

• 5. The therapist engages the necessary auxiliary therapists for the trauma exposure session.

• 6. The patient asks a trusted family member or a friend to accompany them home from the therapist's office after the trauma exposure session and to stay overnight in their apartment.

• 7. The trauma processing session with auxiliary therapists lasts two to four hours. There is no time limit for the end. The session takes place as follows:

  • a. The patient and the auxiliary therapists get to know each other.

  • b. The leading therapist divides the stage and, together with the patient, sets up the control room, the safe place, the observation and narration room, and the interaction room between the perpetrator and victim as planned.

  • c. The other players take on the roles assigned to them by the patient in these work rooms.

  • d. The patient and the therapist sit on two chairs in the narration and observation room. The patient narrates his memories of the trauma situation chronologically in individual sections. In doing so, the patient pauses at regular intervals so that the auxiliary therapists can enact the respective events.

  • e. The auxiliary therapists replay the individual sections of his trauma memory in the action room in the playback format. An auxiliary therapist takes on the role of the patient as a doppelganger.

  • f. Every now and then, the therapist lets the patient move from the narrative room to his ‘safe place’ to resolve any existing dissociating (see Sect. 5.10.5). She knows that as a therapist, one often doesn't notice that the patient is dissociating.

  • g. The patient should himself go into the action room of his trauma scene at least once. Sometimes just 20 s are enough for this. The patient takes on his own role at the place and time of his trauma experience and acts in his role. This helps him to connect his thoughts and linguistic concepts in the traumatizing situation with the split-off sensorimotor interaction patterns, physical sensations, and affect and thus resolve the dissociation. He never changes roles with the perpetrator (see Sect. 5.10.9).

  • h. In any case, the events in the trauma scene should be expanded to include the patient’s corrective fantasy. As a result, the patient internally gains the ability to act in the traumatizing situation. The cave has an exit after all. The patient and the therapist have defined this together in the preparatory sessions.

  • i. At the end of the trauma exposure session, the patient goes to his ‘safe place’. He stays there until he is entirely calm again.

  • j. During debriefing, those involved in the trauma processing session give role feedback and possibly a sharing. The therapist draws attention to new insights that the patient or the other players have gained during the trauma processing.

• 8. The patient is picked up by his caregiver. This person then accompanies him home as planned. The patient should feel safe on the way home and also have someone to talk to at night if necessary.

• 9. The patient and the therapist process the patient’s later reactions to his trauma exposure session in two to three further individual sessions (see Sect. 5.10.8).

The process of trauma processing with auxiliary therapists requires 7 to 15 therapy sessions in total. Therapeutically, the preparatory sessions are just as important as the trauma exposure session.

5.10.4 The Information and Control Space

People with trauma-related disorders are prone to assessing arousal stimuli as a general threat and reacting immediately with aggression or withdrawal, because of the neurophysiological changes in their brain processes and some hormonal changes (van der Kolk, 1998, p. 72). But careful planning of the trauma exposure session reduces the patient's level of anxiety. The therapist and the patient agree on, for example, how long the patient should take on his role in the interaction room of the trauma scene. During the trauma processing session, the therapist ensures that all the agreements made between her and the patient are fulfilled. Sixteen years after her successful psychodramatic trauma processing, the trauma survivor Jill in the case example by Karp (2000, p. 82), said: “Being in control was the key because when it happened, I was not in control of anything”. Dayton (2000, p. 120) says: “Psychodrama can help an individual… gain mastery and control over their environment.” Roine (2000, p. 94) experienced: “By constructing the traumatic events in psychodrama, the protagonist is encouraged to control the situation in a new manner.” Burmeister (2000, p. 212) justifies his approach in trauma work with traffic victims in a similar way: “The protagonist should control and maintain empowerment over the re-exposure of the trauma as the main goal of this stage. Otherwise, retraumatization might rupture the therapeutic and healing effect of the work.” During the trauma exposure session, if a patient moves from the information and control room to one of the other work rooms, the chairs remain where they are. This makes it easier for the patient and the therapist to return to the control room if necessary and to plan the further course of the session together.

Recommendation

“The director should make every effort to prepare for the session by explaining what will happen at each stage of the process and get the protagonist's consent to participate in each part of the work.” (Kellermann, 2000, p. 35).

Case example 44

A 35-year-old teacher was traumatized by being hospitalized when she was five years old. She had an emergency operation to remove her appendix. For a year before, her parents had interpreted her nocturnal abdominal pain only as a desire for attention. Her parents did not visit her in the hospital. The nurses forbade her to cry. They said, ‘Otherwise, you can't go home.’ The little girl had not been informed about what was going to happen to her. She, therefore, seriously believed that she ‘had been sold’. When planning the trauma exposure session, the therapist and the patient agreed that a doppelganger and other auxiliary egos should act out her trauma memories.

However, the therapist and the patient agreed to change the trauma situation. A ‘good mother’ should stay with her throughout her hospital stay. A good mother should inform her of everything that is going to happen. She should comfort her, protect her, and check in with the doctor if necessary. In the trauma exposure session, the auxiliary therapists began by enacting the hospital scenes as the patient remembered them. A doppelganger took on the role of the patient. The patient herself took on her role in the action room of the trauma scene only in the planned desirable scene. After the play, the patient was astonished: “That's strange: I had thought that my wish that my mother would stay with me was completely exaggerated and unreal. But now I've noticed in the play: What I wanted is now standard practice in hospitals as rooming-in. Today it is normal for mothers to spend the night in the hospital with their children!”(Continued in Sect. 5.11). The patient’s family had been dominated by a traumatized father. She was probably a ‘difficult kid’ after being hospitalized as a result of her own trauma. In identifying with the defenses of the family, she developed a masochistic self-censorship. Even as an adult, she automatically blocked the emergence of wishful thinking in herself (continued in Sect. 5.11).

5.10.5 The Safe Place

Traumatized people often spontaneously develop a compensatory counter-fantasy of a world in which the violence and horror of the trauma event do not exist. These counter-fantasies help them to get out of their dissociative states, feelings of powerlessness, confusion, or loss of a relationship. For example, neglected children often imagine that their parents are not their birth parents and that their birth parents will eventually come and take them home. This makes it a little easier for the children to endure violence or neglect from their present parents. Or they read books in which the good triumphs over the evil. Such counter-fantasies invalidate the perception of current reality (Wurmser, 1998, p. 425 f.). It enables those affected to act in their internal conflict processing. In psychodramatic trauma therapy, the patient realizes such a compensatory counter-fantasy with the help of the ‘safe place’ technique and sets it up externally in the therapy room.

Important definition

The safe place is a fictional fantasy room on the stage or in the inner imagination. It should provide absolute support and security to the process of self-development in the fictional situation. The patient should experience what he needs as a counter-image to his trauma experience. This place should not be accessible to the patient's real present or past caregivers because real caregivers from the present or the past always have a negative side. For example, they had limited power to change the trauma situation or because they died.

Case example 45

Ms. D. was a middle-aged patient with post-traumatic stress disorder (F43.1). She suffered from severe sleep disorders, panic attacks with palpitations, and death fantasies. These symptoms were to be understood as flashbacks from the experience of an attempted rape twenty years ago. The perpetrator broke into her car at the time, pressed a knife to her neck, and verbally threatened to kill her. Before her trauma exposure session, the therapist works out, together with her, her ‘safe place’ on the stage. To do this, he separates an area in the group room with a rope: “This is the area for your safe place. Imagine a different world in this room where you feel safe and secure.” The therapist and Ms. D. look for all the elements she needs in the safe place. In the end, Ms. D. installed a CD player in it. She can turn it on, and her favorite Kantate by Bach plays in the room. The patient also imagines a guardian angel there. The angel is supposed to cover her protectively with his wings when she flees to her ‘safe place’ during trauma processing.

Three weeks later, during trauma exposure, Ms. D. once again moves to this protected work room at the end of the session. An auxiliary therapist plays the role of the guardian angel and gives her a compassionate and protective hug. Ms. D. begins to twitch uncontrollably all over her body. Her twitching is gradually becoming more frequent and violent. Finally, she cries cathartically from the bottom of her soul. Her horror, frozen for over 20 years, dissolves in the process. It's like Easter when spring comes. The patient's self emerges out of the depth. (Continued in Sects. 5.10.6, 5.10.7, 5.10.8, and 5.16).

When traumatized in adulthood, patients often choose a ‘safe place’ in nature without human beings. They make friends with animals and establish relationships with trees or streams. This place is only accessible to them through a magic word or a hand signal. In the case of relationship trauma in childhood, the ‘safe place’ should also have a fictional figure or person who gives the patient the needed support and security. The therapist takes the following steps in working together with the patient to develop their personal ‘safe place’:

• 1. She sits with the patient in the information and control room. She uses a rope to draw a boundary around the ‘world of the safe place’ and sets up an empty chair for the patient in this area: “This is a world in which you are absolutely safe and secure.”

• 2. She asks the patient about a painful past situation where he would have needed safety and security.

• 3. Together with him, she senses his emotions in the difficult situation and names them: “You felt totally powerless” and “… totally abandoned”. “You could no longer feel anything”. “You stood next to you …”.

• 4. Together with the patient, she looks for a fictitious situation that would trigger the opposite emotions in him: “In this other world, you feel absolutely safe and secure. You can feel something again, and you become yourself.”

• 5. The therapist points to the separate room of the ‘safe place’: “There in the other part of the room is a place where you can find everything that you would have needed in this situation. What should happen in this other world so your wish can really come true? What all should be there?”

• 6. The therapist asks the patient: “Have you ever truly experienced trust, support, and security in your life?” She also asks about transpersonal experiences in nature, music or art, religion or love (see case examples 32, 40, 41, and 42).

• 7. The therapist lets the patient go in a separate room of the ‘safe place’. But she herself remains standing on the border between the two worlds. She thereby attests through action to the existential quality of the ‘safe place’. The ‘safe place’ should return to the patient his dignity as a person in his feelings, thoughts, and actions, and his physical and mental integrity.

• 8. Together with the patient, the therapist symbolizes, with objects, the experiences of security he has already mentioned (see 6.). The patient places these symbols in the ‘safe place’.

• 9. In the second step, the therapist and the patient add missing elements to the construction of the ‘safe place’. For example, they look for a person or a figure from a fairy tale or from literature who would accept the patient as he is in his safe place and support him consistently. If auxiliary therapists or group members are present, they can take on the role of auxiliary egos in the safe place. For example, they play the role of a tree or a guardian angel.

• 10. The patient explores the situation in his ‘safe place’ in his own role in the as-if mode of play by acting. For example, he hears the imagined sea birds. He is able to see the sea and smell it. He feels the comforting or protective gesture of the wise old woman physically and mentally. In individual therapy, the therapist replaces the wise old woman's embrace by giving the patient a blanket ‘to warm himself’.

• 11. The patient should not move into the counter-role of the supporting fictional figure or a living being in his ‘safe place’, not even to ‘show how they should behave’. This could trigger a flashback or a pathological regression because the protagonist sees himself, from the role of the good fictional figure, as in a mirror with his neediness, absolute loneliness, or confusion. This triggers intense compassion in him and he may be overwhelmed by the victim’s feelings in identifying with him. In his own role, however, the patient has control over the extent to which he allows his feelings to surface. He can lean against the person giving protection, ‘just’ sit next to them or simply walk away again.

Central idea

The patient regains access to his split-off sensorimotor interaction patterns, physical sensations, and the affect of his trauma experience by acting in his “safe place”. Self-stabilization is a stabilization of inner self-development in an external situation that provides support.

• 12. Often patients are timid and modest in their wishes when building their ‘safe place’. The therapist then feels the patient’s pain and longing as a doppelganger on his behalf. In such a case, the therapist draws the patient's attention to the additional possibilities in the ‘safe place’: “Your safe place is a fantasy world. You can actually make your wishes come true in this fantasy world! You said the wise old woman comforts you. Does she really just sit next to you and listen to you? Or is she perhaps caressing your back as well?”

• 13. Sometimes the patients may masochistically feel guilty in response to their desires. The therapist symbolizes these with building blocks, if necessary, but places them outside the ‘safe place’ in the ‘real world’ separated by the rope. The ‘safe place’ should be where wishes are still helpful.

• 14. When the safe place is completely set up, the therapist prompts the patient: “Please walk around the room of your safe place again. Make contact with each of the existing elements. Feel yourself as you do it!”

• 15. The therapist asks the patient to return to the ‘real world’ by stepping over the rope.

• 16. She discusses with him his experience in his ‘safe place’. Together with him, she also names what he physically felt and experienced in the ‘safe place’.

• 17. She asks him: “In the next two hours, please write down everything that belongs to your safe place and what happens there. Otherwise, you might forget important elements or actions”.

• 18. She recommends to the patient: “Visualize the experience of your safe place at home in your mind. Or play out the encounters from your safe place at home in your living room, just as you acted here in therapy. You are allowed to beautify and positively expand the events in the safe place. Practice the safe place technique as a self-stabilization technique at home! Use the technique when dissociating.” The diverse actions and perceptions produced in the external ‘safe place’ in the as-if mode of play activate the experience of security and safety even at the sensorimotor level.

Recommendation

If you want to develop a ‘safe place’ with a patient, photocopy the following list of elements of a ‘safe place’ beforehand. You can then use this list as a guide during your work.

• 1. Elements that stabilize the inner self-image in the patient's inner thinking:

  • a. The therapist specifies the patient's positive abilities and strengths individually with stones or wooden blocks and places them in a corner of the safe place on the floor. Many patients struggle to ascribe positive abilities to themselves. In such a case, the therapist asks: “What does your friend, daughter, or colleague like about you?” The patient sits in the safe place on the floor during this work. He takes every one of his ‘abilities’ in hand and actively assures himself of this ability. This self-stabilization technique is a resource work. It can also be practiced as an independent self-stabilizing technique without the ‘safe place’ technique.

  • b. If necessary, the patient represents his own healthy inner child, which he may have been before his trauma, in his ‘safe place’ with the help of an auxiliary therapist or a puppet. He interacts with him in the as-if mode of play and forms a relationship with him.

  • c. Some patients have discovered the ability to stabilize themselves through manual or artistic activities. In doing so, they experience themselves as self-effective and creative. In such a case, the patient should also place the appropriate tool, for example, the saw, the violin, or the painting board, in his ‘safe place’, thereby giving his self-efficacy some space in his soul.

Case example 46

A 52-year-old patient remembers his ability to develop new solutions in model airplane construction while developing his ‘safe place’. He brings one of his model airplanes with him for his psychodramatic trauma exposure session and a television with a video recording of his model airplane flying. Furthermore, the therapist and the patient seek a memory symbolizing a feeling of absolute security. The patient remembers: As a four-year-old, he sat on the steps of his parent's house and listened to the ‘competition’ between two church bells: “One was much more melodic, and it always won in the end. It was also slower, but it rang longer than the others.” The patient smiles at this memory, relieved: “I used to remember that a lot in the past. But I haven't thought about it for three years until now”. Three weeks later, the patient brings a tape recording of the church bells from his childhood for the session of his trauma exposure. The week before, he had gone to his hometown, 200 km away. He recorded the ringing of the church bells that are still there with his tape recorder: “I tried that first at 10 o'clock in the morning. But there were too many cars that disturbed the ringing. I then waited an hour. I could successfully finish recording at 11 o'clock” (Continued in Sect. 5.10.8).

• 2. Fictional persons, living beings, and symbols that give the patient support as a relational object in his safe place:

  • a. These can be transpersonal roles from nature, trees, forests, or rivers. Or figures from religion, for example, a guardian angel. Or a figure from literature, mythological stories, or fairy tales, such as the seven dwarfs from ‘Snow White’ or the magician Gandalf. Or people from a movie, Master Yoda or E.T., or symbolic people from history, Martin Luther King, Gandhi, or similar.

  • b. The patient can also record a piece of music he loves on a DVD. He can then let it play on repeat in his ‘safe place’ (see case example 45 above).

  • c. In the ‘safe place’, ‘animals’ can wait for the patient. These help him, just like the doves in the fairy tale of Cinderella or the seven animals in the grim fairy tale of ‘Two Brothers’.

  • d. The patient can place a fictional wise old woman or a wise old man on a chair in the ‘safe place’. Or he can represent his role model there: This person should have survived a similar emotional trauma. But they have processed their fate well and become wise as a result.

  • e. The patient can free himself from his flashback in a sensorimotor way by dancing to his music or engaging in other physical activities in his ‘safe place’.

• 3. Elements that represent a healing, existential experience of the patient: Some patients have had a profound healing experience in art, nature, religion, or love. The therapist lets the patient symbolize such an experience with an object or an auxiliary ego in the safe place. For example, this can be a tree, a forest, a river, or a guardian angel.

The therapist helps the patient shoulder to shoulder as an implicit doppelganger in developing his ‘safe place’. She is also allowed to express her own ideas in the process. The therapist's proposals do not seem directive when expressed shoulder to shoulder. Instead, they open up the potential space for the patient's imagination. They activate his mentalization and stimulate him to find his own ideas for his ‘safe place’. The ‘safe place’ technique presented here includes several self-stabilization techniques.

Central idea

Some patients find it difficult to develop their ‘safe place’ because of their masochistic self-censorship. This technique is particularly beneficial for those patients. But, the therapist takes very small steps. Disorder-specific trauma therapy is patient work in the right place.

Recommendation

Participants in group therapy or an advanced psychodrama training group should each develop their own ‘safe place’. Thus, disorder-specific trauma processing is possible in a group (see Sect. 5.10.11).

5.10.6 The Observation and Narration Room

In the case of unprocessed trauma, the original coping through dissociating solidifies “more and more into symptoms. […] The life-saving function of dissociation becomes the symptom of dissociative disorder. Since the organism has tried to heal itself with these coping strategies, we assume that these coping strategies are useful” (Reddemann, 1999, p. 89). The disorder-specific psychodramatic trauma processing helps the patient to dissolve the split between the cognitive and the psychosomatic process of conflict processing by acting in the as-if mode of play (see Sect. 2.6) and to bring it under the control of his ego (see Sect. 5.10.2).

During trauma processing, the patient thinks and talks predominantly in the narrative and observation room and tells his trauma story from there. The external distance helps the patient also gain an internal distance from the trauma scene. A doppelganger and the auxiliary therapists re-enact individual interactions from the patient’s traumatic history in the interaction room using the playback method. The patient usually goes into the interaction room of the trauma scene just once for a short time. The patient perceives himself from a meta-perspective and gives instructions to the playback actors. Karp (2000, p. 79) reports about her patient Jill: “The distance provided safety. The protagonist instructed and watched group members play out her scenes, occasionally entering the scene to correct the action. For example, …because a broken bottle held to her neck, … was held in the wrong place…. It had to be represented exactly as it happened and with her in control of the information.” The meta-position helps the patient develop self-empathy for her traumatized acting ego.

Acutely traumatized patients should narrate their trauma story from the narration and observation room, and direct the interactions of their auxiliary therapists from there. The goal is that they “… see what had happened… without becoming overwhelmed… and… start to process the perceived information cognitively… Such cognitive re-processing of traumatic events… enables traumatized people to make sense of a world that has momentarily lost structure and meaning” (Kellermann, 2000, p. 29; Karp 2000, p. 68 ff.). For example, an acutely traumatized patient had witnessed a terrorist bomb attack with many fatalities (Kellermann, 2000, p. 29). He came to the therapist in a dissociative state of consciousness. He complained: “Everything seems so unreal as if I am in a dream or a movie.” He had split off his emotions and sensorimotor experience and was acting from his observing ego (see Sect. 5.10.2). The therapist set up a chair next to him for his observing ego. He let the patient change roles from his acting ego into the role of his observing ego. The patient then narrated his trauma story from that role. A doppelganger and some auxiliaries re-enacted his trauma story on his behalf in the interaction room. In this way, the patient connected his cognitions to his split-off emotions. He dissolved his dissociative state of derealization by crying cathartically.

During trauma processing, the therapist sits or stands shoulder to shoulder as an implicit doppelganger (see Sect. 2.5) next to the patient in the observation room. Together with him, she looks at the interaction room of the trauma scene and, as a doppelganger, helps him to name things appropriately. For example, she describes violence in the trauma scene as ‘violence’ and abuse as ‘abuse’. Collaboratively naming and thinking about his trauma experience activates and expands the patient’s cognition. In this way, the patient integrates forgotten or denied interaction sequences (see Sect. 2.4.2) into his trauma memory. He captures the cause and effects and further develops his traumatic experience into a coherent story.

Central idea

Trauma patients often falsify the logic in their trauma memories retrospectively through masochistic self-censorship (see Sect. 8.5) and forget their own brave actions in the traumatizing situation. However, the auxiliary therapists replay the trauma story step by step during trauma processing. This helps the patient, looking at this process from the meta-perspective, to reveal contradictions between his remembered actions and his subsequent interpretation of these actions.

In the case example by Karp (2000, p. 63 ff.), patient Jill knew cognitively, even before the trauma exposure session, that her daughter and husband had actually survived the attack and rape in Africa because the family was living together again in England. Despite this fact, she could also really feel this only after the psychodramatic trauma processing. The patient in case example 40 (see Sect. 5.9) reported two years after his trauma processing session: “Before the trauma processing session, I always felt and thought: ‘I am wrong’ and ‘You didn’t manage anything’. In the trauma processing session, I learned how smart and clever I actually was as a child. The little boy in me is precious!” Because of her mental paralysis in her nightmares, the patient in case example 45 believed wrongly that she had not resisted the rape attempt.

Case example 45 (1st continuation, see Sect. 5.10.5)

During the trauma exposure, Ms. D. narrates the story of the attempted rape from the observation room. She reports what she did as the victim and what the perpetrator said and did. As the victim, she tried to move the rapist's knife away from her neck and grabbed the sharp edge in the process. She wrestled with the perpetrator for a long time and suffered cuts on her neck and hands. The auxiliary therapist, who takes on the role of the patient as a doppelganger, re-enacts the described interaction sequence in the action room. In this case, the perpetrator is represented only by a chair. The doppelganger defends herself in the role of the patient on stage, just as the patient had reported in the narrative room. She screams for help in fear of death. Her scream is so loud that everyone involved feels the fear of death.

At this time, the therapist stands shoulder to shoulder next to the patient in the observation room and actively verbalizes what he sees as a doppelganger: “You fought! And how! You fought and wrestled with the man for three-quarters of an hour and even grabbed the knife! Where did you get so much strength from!” During the debriefing, Ms. D. said in astonishment: “I didn't remember that I fought so hard because I am always completely frozen in my nightmares and cannot defend myself!” She continues to share that after 45 min of fighting with the perpetrator, she was so exhausted sitting in the car seat behind the wheel that she stopped resisting: “I then asked him: ‘What should I do? What is going to happen now?’” The therapist interprets even this behavior of the patient as quite courageous and appropriate: “When you couldn’t go on, you still didn’t give up. You kept looking for a solution!”.

Eight weeks after the trauma processing, the patient stated: “I had always thought that the perpetrator could do whatever he wanted with me, that I was a plaything for him. Now I know that I fought back. I was, in fact, brave and courageous! I am now aware of this at night too. I can defend myself! Feeling paralyzed was the worst!” By re-enacting it in the play the patient expanded her memory into a holistic psychosomatic experience and re-established a relationship with her creative ego. That made her even more courageous in her everyday life: “I have finally opened up and told a long-time friend that his presumptuous overconfidence bothers me. But after the phone call, I wasn’t feeling well at all. I have to be careful not to overreact” (continued in Sects. 5.10.7, 5.10.8 and 5.16).

5.10.7 The Interaction Room Between the Victim and the Perpetrator

In my experience, many psychodramatists are willing to be part of a trauma processing session as a doppelganger and an auxiliary for a low hourly wage because they are often fascinated by the existential dimension of work. Before the actual trauma processing session, the therapist takes the patient’s consent and shares the trauma story with the auxiliary therapists. Together with them, she decides which of the usual complex roles they will enact.

Recommendation

Trauma processing is like collaborative white water rafting. One cannot get out of the boat while canoeing in white water. When processing trauma, everyone involved must go through the heart of the trauma together with the patient. If the therapist avoids this, the patient intuitively feels that even the therapist cannot endure the horror of his traumatic experience. This confirms his conviction that he is ‘a burden’ on the world. Therefore, trauma processing requires the therapist to make a clear decision on whether she wants to go white water rafting with her patient.

Central idea

By definition, trauma processing results in the patient dissociating. Therapists often do not notice this because the patient is able to talk about his trauma cognitively. Therefore, in debriefing, the patient can honestly say (see case example 14 in Sect. 2.12.2): “That was not new for me. I already knew all that.” Only the therapist feels the threat and horror of the patient’s trauma experience vicariously. Trauma processing requires the patient to dissociate and then resolve his dissociation through immediate self-stabilization. Because otherwise, the split between the cognitive and psychosomatic memories does not resolve. For this purpose, the patient must appropriately switch back and forth between the four work rooms of self-development in trauma therapy (see Fig. 5.2 in Sect. 5.10.2).

During trauma processing, the patient enters the interaction space of the trauma scene at least once for twenty seconds. In doing this, he does not necessarily have to meet the ‘perpetrator’ in the trauma scene. For example, Karp (2000, p. 71 f.) only asked her patient Jill to psychodramatically enter the spatially separated space of her experience of violence when her family members had all been saved in the re-enacted trauma story. The ‘violent perpetrators’ had already left the place of attack and rape. In the play, she was supposed to ‘only say goodbye to her servants before moving from the African city to England’. ‘Protected by the safe environment of the group’, the protagonist entered the action room of her trauma scene. She immediately started trembling. All her emotions pent up for years discharged into an hour-long cathartic cry. The patient then slept for thirty hours without a break. She had previously suffered from severe insomnia for years.

Case example 45 (3rd continuation, see Sects.  5.10.5 and 5.10.6)

Ms. D.‘s trauma was processed more than twenty years after the attempted rape. When telling her trauma story in the narration and observation room, Ms. D. had not yet entered into the affective and sensorimotor experience of her trauma memory. Even in this case, the therapist let the patient change into her role in the action room of the trauma scene when ‘the perpetrator’ had already fled. Soon after taking a few steps into the action room of the trauma scene, Ms. D. noticed that she was beginning to panic. Nevertheless, she took a seat in her ‘car’, represented by two chairs, in which the rape attempt occurred. At that moment, she was ‘dizzy’. Her heart started racing, and she was gripped by an intense fear of death, much like in her nightmares. The therapist immediately asked the patient to return to her ‘safe place’. There the ‘guardian angel’ held her in his arms. An auxiliary therapist played this role. Her favorite music, a special Bach cantata, played in the background. Ms. D’s twenty years long pent-up emotions dissolved into an intensive integrative catharsis.

In the following weeks, her panic and the subsequent cathartic state repeated three more times when she was home. However, this time ‘she knew that unlike before, things would end well’. The flashbacks that had tormented the patient every night for twenty years had disappeared for eight weeks. They then came back for a few days. Appropriate processing of the conflicts that had triggered the flashback ended this ‘relapse’ immediately. (Continued in Sects. 5.10.7, 5.10.8 and 5.16).

Central idea

When one remembers a traumatic experience, the associated emotions, actions, and sensations remain disconnected due to the dissociation that sets in. As dissociation prevents all access to one’s self-awareness and emotions, the corresponding information is stored as expert knowledge in the left hemisphere and not integrated into the right-brain procedural memory and the autobiographical-episodic or context-related memory (Markowitsch, 2001, pp. 75, 84 f.). Without trauma processing, the gaps in trauma memory often exist for the long term. These gaps are eventually filled with self-destructive assumptions to make sense of the fragmented experience.

5.10.8 Processing the Reaction to the Trauma Processing Session

The therapist continues to support the patient for at least eight weeks after his trauma exposure session. She helps him to process the new experiences and integrate them into his self-image. In this way, she prevents the risk of the patient inappropriately questioning his new experiences during the trauma exposure session in the event of a new flashback.

Case example 45 (4th continuation, see Sects. 5.10.5, 5.10.6, and 5.10.7)

One week after her trauma processing session, Ms. D. considered ending the therapy: “I feel like I'm in heaven, and I want to preserve this feeling”. As a result, she was all the more shocked when her flashbacks reappeared at night eight weeks after the trauma exposure. These were triggered by a trip with friends with overnight stays out of the house. Ms. D. felt like a failure. The therapist worked with her to find the cause: the patient had told her friends about her trauma processing session. Her friends were quite inquisitive. But they could not really appreciate the existential depth of the patient's experience. Their superficial reaction made the patient feel different from others again. She felt marked by an adverse fate and feared she would stay that way forever.

The patient had to learn that the existential dimension of her experience truly made her a unique personality in a positive sense. The therapist: “You mustn't overwhelm other people! Your girlfriends did not experience your trauma processing. In my experience, only 10–20% of people have had similar existential experiences as you did when you came to terms with your trauma. Only one in five people can understand what you are talking about! Other people are unable to feel the existential dimension of such an experience. In the future, please check whether the person you share your experience with only reacts superficially or really understands you!” The patient's flashbacks disappeared after this clarification.

On the advice of the therapist, Ms. D. also symbolized her successful trauma processing concretely. She found a small, pretty box and placed in it a symbol of the precious experience of the trauma exposure session. She tied this box with a woolen ribbon and placed it on her desk: “Before the trauma session, I felt very alone. I don't usually have that feeling anymore, although I notice that I'm getting lonelier”(continuation in Sect. 5.16).

Central idea

Trauma survivors live with the scar of Harry Potter on their foreheads all their lives. Successful trauma processing is both a win and a burden. It often leads to post-traumatic growth. However, because of the hidden transpersonal truth, a part of the survivor’s soul feels alienated, and they also alienate other people.

Sometimes, in the case of childhood trauma, the patient is so firmly fixed in his defense that individual fragments of the trauma memory only surface a few days after the trauma processing session. It is then important to recognize them as elements of the trauma experience and to actively link them to the patient’s trauma story.

Case example 46 (1st continuation, see Sect. 5.10.5)

40-year-old Mr. B. suffered from dysthymia (F34.1), migraines, and narcissistic personality disorder (F60.8). His trauma exposure session lasted three hours. His trauma memory was about the surgical excision of an eye because of suspected cancer when he was five years old. As a grown man, the patient was still convinced that the operation had been ‘performed without anesthesia’. After the trauma exposure session, Mr. B. doubted whether the intensive work had helped him in any way because he did not get the expected cathartic reaction.

However, three days after the trauma processing session, the patient had anxiety attacks when relaxing at home. His attacks suddenly shot up ‘from the back and constricted his neck’ for a minute each time. The therapist had the patient re-enact one of his anxiety attacks psychodramatically. In doing so, he asked the patient to think of a symbolic image that would go well with his feelings of fear. Mr. B. imagined a long hallway in a hospital. He is alone. He is five years old. The walls on the right and left are bare. The corridor is covered with a beige linoleum floor. The hallway is dark, and one can only see a light window at the end of the hallway. As a child, he feels lost, helpless, and alone. He doesn't know what happened to him or what might still be planned for him. The therapist then interpreted the patient's anxiety attacks as flashbacks. This connection between his anxiety attacks and his childhood trauma experience liberated the patient from self-doubt. In the following therapy session, he reported: “I have started cleaning up my neglected apartment. It looked just like me inside.” The patient appeared alive and optimistic for the first time in months. He wasn't depressed anymore.

Recommendation

Psychodrama therapists should participate in a patient’s trauma processing session as auxiliary therapists at least once. The playful use of the four work spaces for psychodramatic trauma processing (see Fig. 5.2 in Sect. 5.10.2) improves one’s intuitive sense of dissociation in traumatized people. In addition, the internal imagination of the four involved work spaces makes it easier not to get caught up in countertransference reactions in practical work.

5.10.9 The Contraindication of Reversing Roles with the Perpetrator

None of the nineteen authors of the book ‘Psychodrama with Trauma Survivors’ (Kellermann and Hudgins, 2000) wrote about a role reversal with a perpetrator in any of their forty case studies. Many psychodrama therapists even consider the role reversal with the perpetrator to be explicitly contraindicated (Burmeister, 2000, p. 213; Kellermann, 2000, p. 37; Pruckner, 2002, p. 106 f.). There are two reasons for this:

• 1. The direct encounter with the perpetrator in a play is, by definition, equivalent to trauma exposure. It makes the patient dissociate. Often the therapist doesn’t really notice it. The patient splits off his sensorimotor interaction patterns, physical sensations, and affect from his perception and is mentally absent in the play (see case example 14 in Sect. 2.12.2).

• 2. Trauma patients often misunderstand the therapist’s instruction to reverse roles with the perpetrator as a subtle message. They interpret it as they should learn to understand and accept the perpetrator's motives (Kellermann, 2000, p. 37). However, this increases their auto aggression, their shame, as well as their feelings of guilt.

Some of the authors of the book ‘Psychodrama with Trauma Survivors’ (Burge, 2000, p. 307; Karp, 2000, p. 70; Leutz, 2000, p. 190, 195; Roine, 2000, p. 95f.), fall into the diffusion trap in their theoretical considerations (see Sect. 2.14) and, still consider role reversal to be an ‘important technique’ in working with traumatized people. Burge (2000, p. 307), for example, hypothesizes that reversing roles with the perpetrator allows a protagonist to regain access to his own anger because, in doing so, he experiences the perpetrator’s sadism and anger physically and mentally. However, his assumption is a theoretical assertion that cannot be proven in practice (see Sect. 8.4). Burge did not use role reversal with the perpetrator in his case examples. He did not even let the respective ‘perpetrator’ appear in the two plays he described. Karp and Leutz do not describe the role reversal with the perpetrator, but ‘only’ with a third person present in the trauma event, a fellow victim. Roine (2000, p. 95 f.) also, in theory, hypothesizes that traumatized people with a small repertoire of roles “experience an augmented reality when they reverse roles with the perpetrator and are better able to reclaim their own authentic selves”. However, this theoretical assumption is misleading. In doing so, the patient succeeds only in relationships with authoritarian attachment figures, and not in the relationship with a real perpetrator. In these cases, the patient gains access to his self because he resolves his defense through identification with the aggressor through role reversal (see Sect. 2.4.3).

Lesemann (1993, pp. 83, 95) is the only author I know who describes the role reversal with the perpetrator in his own case study. He completed a long, overall successful therapy process under supervision. The supervisor advised him that it was necessary to reverse roles with the perpetrator ‘to bring the therapy process to an end successfully’. Lesemann tried to put this suggestion into practice twice. His traumatized patient entered the interaction room of the trauma scene during the first attempt to meet her perpetrator but immediately stopped the play and ran in panic out of the group room into the hallway. A few weeks later, during the second attempt, she obediently followed the therapist's instructions and reversed roles with her ‘perpetrator’. However, if you read Lesemann's article carefully, it becomes apparent that the role reversal did not have any additional positive therapeutic effect on the patient. Fortunately, it didn't harm the patient either.

5.10.10 Trauma Processing Using the Table Stage in Individual Therapy

In individual therapy, the therapist uses the table stage to process trauma. Auxiliary therapists are not involved as doppelgangers and auxiliaries. After the trauma-specific diagnosis and crisis intervention, the traumatized patient first learns the necessary self-stabilization techniques (see Sects. 5.7 and 5.9). In doing this, the patient should also develop their own ‘safe place’. Thereafter, the therapist and the patient plan the actual trauma processing with all the associated steps. The therapist informs the patient about the four work rooms for trauma processing by externally symbolizing them in the therapy room. Together, the therapist and the patient determine how the events in the trauma processing session should go on in time. They work out what the patient would have needed in the traumatizing situation and what shouldn't have happened. During trauma processing, the patient should sit on his chair in the narration and observation room and tell his trauma story. As a doppelganger, the therapist enacts all that the patient shares, on his behalf, with stones and wooden blocks using the playback method on the table stage (see Sect. 5.7).

Recommendation

When processing trauma with the table stage, the therapist always limits the work to only one traumatic event in a session. This reduces the risk of pathological regression for the patient. The patient can process other traumatic events in other sessions.

In the actual trauma processing session, the therapist lets the patient move back and forth between the different workrooms, just like when working with auxiliary therapists (see Sect. 5.10.3–5.10.8). Together, they perform the following steps:

• 1. In the beginning, the patient sets up his ‘safe place’ on the room stage, three meters away from the table stage.

• 2. The therapist places two empty chairs beside each other, far from the table. They represent the ‘narration and observation room’. The first chair is for the patient as the narrator of his story (Fuhr, 1995, only orally communicated) and symbolizes his ‘observing ego’. The second chair is a chair for the therapist as an implicit doppelganger: “This is me as a therapist. I will help you tell your story from this position”.

• 3. The interaction room of the trauma memory is located on the table. The therapist sits at the table and places an ‘ego stone’ on it for the patient. The patient sits in his chair in the narrative room three meters away. The therapist asks him: “Can you see the stone on the table from there? This stone represents your ‘ego’ in the traumatic situation”.

• 4. The therapist stands up and sits shoulder-to-shoulder next to the patient in the narrative room. She asks, “How do you feel when you look at yourself there on the table? Please, have a soliloquy here in the observer position!”

• 5. The therapist: “‘When I see what was going on in your school from here, I see the nine-year-old Rolf, who …’ Please narrate your trauma story in the third person and not in the first person!” The patient talks to the therapist about ‘little Rolf who …’, about ‘the man who …’, ‘the child who …’, ‘the little girl who …’ or ‘the woman who …’. “This helps the patient and the therapist to distance themselves internally from the pull of the trauma experience.

• 6. The patient talks about who was present in the traumatizing situation from his chair in the observation room.

• 7. The therapist sits down at the table again. She represents the elements of his trauma story on the table with stones, wooden blocks, or even small dolls: (1) the patient's acting ego, (2) his feelings, (3) the people involved, and (4) the important objects.

• 8. Together, the therapist and the patient should go through the heart of the patient’s trauma memory. Therefore, the therapist asks him: “What was the worst feeling for you in the traumatizing situation?”

Central idea

Therapists often misjudge the worst part of the patient’s experience of the traumatizing situation. For example, they believe that when a patient was hit in childhood, the pain was the worst experience for the patient. However, the patient may respond: “It was the feeling of humiliation and shame.” This is because, as a child, the patient would sometimes dissociate and thus, didn’t feel any physical pain.

• 9. While sitting on his chair three meters away, the patient narrates from the beginning to the end step by step what happened to the little boy in the traumatizing situation, as well as what he felt, thought, and did in the situation at the time.

• 10. As a doppelganger and an auxiliary, the therapist replays the interactive events in the traumatizing situation with empathy and fantasy using the symbols on the table. She acts as if she is playing with a doll's house.

• 11. As a doppelganger, she expresses what the little boy on the table in the trauma scene feels and senses physically. She screams and cries on his behalf.

• 12. The therapist occasionally interrupts her play on the table stage and goes to the patient in the narration room. From there, she and the patient together look at the table stage shoulder to shoulder. As a doppelganger, she names and comments on what is going on at the table stage from the observer position: “This is violence! This is why we have programs for violence prevention in schools today.” “This is nasty and devious.”

• 13. Time and again, the patient moves to his ‘safe place’ in the therapy room to resolve a possible dissociation.

Central idea

The therapist often cannot perceive that the patient is dissociating. Therefore, she follows not only her intuition but also her experience when she asks the patient to go to his ‘safe place’.

• 14. The patient should go to the table stage at least once and touch the stone representing his ‘acting self’ in the trauma scene on the table stage. In this role, he soliloquizes with the help of the therapist. The therapist asks him about the worst feeling in his trauma event and, as a doppelganger helps him to name it: “You feel betrayed”, “humiliated”, and “as if you are nothing”.

• 15. But, after a short time, the therapist lets the patient move back to the ‘safe place’ set up in the room. He should be able to rest there and resolve any possible dissociation.

• 16. The therapist creates the desired coping scene on the table stage. In doing so, she follows the previously agreed plan. She represents the helpers and rescuers with stones or wooden blocks on the table and plays these roles on the patient’s behalf thereby changing the traumatizing scene as desired.

• 17. As an interacting doppelganger of the patient, she follows her own creative impulses in playing on the table stage. In the role of the patient, she mentalizes the patient’s feelings on his behalf. In the other roles, she yells and scares the ‘perpetrator’. She plays out the positively changed interaction sequences of the trauma scene and exaggerates a little bit. She repeatedly asks the patient: “Is that okay for you? Or is it too much?”

• 18. In the positively changed trauma scene, the patient sits down at the table stage for the second time. He touches his ego stone and plays out the interactions in the coping scene together with the therapist. He experiences the positive outcome of his trauma story closely in the role of his acting ego. In doing this, he links his thinking and talking with his split-off sensorimotor interaction patterns, physical sensations, and affect in his trauma memory.

• 19. After enacting the coping scene together, the patient once again goes back to his ‘safe place’ to relax completely.

• 20. The joint debriefing follows.

Case example 47

Other children repeatedly beat up Mrs. D. as a child in school. The therapist re-enacts, on the patient’s behalf, the hurtful incident from school with stones and wooden blocks on the table stage: The girl is eight years old. Other students tease and beat her. When planning the trauma processing, the patient had wished that two elderly students would come and defend her in the desired scene. The therapist lays out the stones for the older students in the desired scene on the table stage. The two older ‘students’ protect the ‘girl’ so that what had happened does not happen again, and what did not happen does happen now.

Trauma processing on the room stage with auxiliary therapists is time-consuming and, therefore, indicated in the case of a single severe trauma experience in a specific place at a specific time. Trauma processing with the help of the table stage is recommended for people who have suffered long-term sexual, physical, or narcissistic abuse. The therapist lets the patient process two or three of their traumatic memories using the table stage, including their worst experience, too.

5.10.11 Trauma Processing in Group Therapy

Participants in therapy groups, self-awareness groups, or training groups often unexpectedly play out one’s own trauma experiences when they act out childhood scenes. But in doing this, the protagonists often dissociate, making the protagonist-centered play therapeutically useless (see case example 14 in Sect. 2.12.2).

Central idea

Traumatized people are world champions in ‘pretending as if nothing happened’. The therapist often does not notice when the patient is dissociating because the patient does not notice it himself and functions perfectly on the outside.

All members in psychodrama groups should develop their own personal ‘safe place’ early on. The leader can help a single participant define his ‘safe place’ in the group (see Sect. 5.10.5). The other participants think of a ‘safe place’ for themselves at home. In the following session, they present their results to the group and add missing elements to their ‘safe place’ if necessary.

If a traumatizing situation occurs unexpectedly in a protagonist-centered play, the therapist proceeds similarly to individual therapy with auxiliary therapists (see Sects. 5.10.3–5.10.8 and Fig. 5.2 in Sect. 5.10.2), but only in one group session.

5.11 Integrating Inner Change into Everyday Relationships

People with trauma-related disorders are psychologically injured and often behave differently from other people in everyday life. They feel ashamed, introject (see Sect. 2.4.1) the criticism of their attachment figures, and masochistically use it against themselves. They often struggle with understanding their otherness. They, therefore, readily accept the way in which significant others interpret their behavior. For instance, the patient in case example 32 (see Sects. 5.1, 5.5 and 5.9) identified with his parents’ norms and values after an eight-month stay in the children's clinic. His parents were only concerned with achievement and success in life. Thus, the patient learned to taboo his desires for comfort and security and perceive them as weaknesses. He learned to invalidate his feelings in a masochistic self-destructive manner. As a result, he tried to conform to a perfectionist performance ideal even in adulthood. He could never enjoy his successes. For example, he needlessly sold his beloved holiday home in Denmark after years of laborious restoration. In the event of threatening relationship conflicts at work, he often withdrew in anticipatory obedience even before his opponents attacked him. As a result, he was an outsider at his workplace for a long time and then became self-employed as a specialist.

Traumatized patients quickly feel threatened in relationship conflicts (van der Kolk et al., 1998, p. 72) because conflicts trigger their traumatic sensorimotor interaction patterns, and affect. For example, they subjectively experience criticism as violent blows. Or they masochistically confuse their external conflict partner with their internal soul killer (see Sect. 8.5). They tend to avoid relationship conflicts, adapt to the expectations of their respective social environment, and function well in terms of the expectations of their relationship systems. They then interpret their own reasonable intentions and desires as ‘evil’ (see Sect. 8.5).

Central idea

Trauma processing helps loosen the fixation of self-development in the defense system of self-protection through denial and masochistic self-censorship. The patient’s self-actualization and self-esteem in dealing with everyday conflicts improve. When therapy is advanced, the patients learn to say ‘no’ and no longer overwhelm themselves as much. This leads to new relationship conflicts at work and in the private sphere.

Progressive changes must be explicitly appreciated as ‘new’ and positively confirmed by the therapist for them to stabilize (see Sect. 2.1). The patient’s new actions in a situation that would previously have triggered a flashback are particularly valuable. Traumatized patients often do not notice the new quality of their behavior themselves. The therapist, however, calls it ‘the patient’s journeyman’s piece’.

Case example 44 (1st continuation, see Sect. 5.10.4)

At the end of her therapy, the 35-year-old Ms. F. spoke to her colleague about the distribution of work at their joint workplace. The colleague looked ‘angry’. This led to an internal state of agitation in the patient, but not to a flashback as before. Ms. F. could speak to the colleague on her own the following day. The colleague reacted differently than the patient's father, who was traumatized by the war, was even ‘relieved’ and said: “I was also hoping to talk to you. I misunderstood something yesterday. I'm sorry”. The women then intensively discussed their experiences by being vulnerable with each other. The following night, Ms. F. was feeling agitated again. But she was able to resolve her agitation differently than before: she actively visualized the difference between her colleague and her war-traumatized father several times. Ms. F. told the therapist: “I then sent my father back into the past to another place and time”. (2nd continuation, see below).

Another patient was forcibly abused by his older brother. At the end of therapy, he was internally highly agitated as he was humiliated as a craftsman by a customer. However, unlike before, he did not regress into his old self-injurious thinking and acting. Instead, he imagined ‘all the trigger boys, who torment him in the present, standing next to each other’. He cried with anger for half an hour and justified his sadness. But he didn't get lost in self-pity. He mourned that his life was so difficult because of his childhood trauma. After this inner work, the patient went to an older maternal friend and talked to her about the difficult customer. The friend knew the customer and confirmed his perception that this man was very difficult. She positively affirmed the patient’s new behavior. The therapist appreciated the patient’s various new solutions in the potentially retraumatizing situation and confirmed that he had created his journeyman’s piece in therapy. At the end of his therapy, the patient in case example 35 (see Sect. 5.5) was also able to actively change his trigger situations in the hospital in such a way that he no longer had a flashback when he saw a man in a white coat.

Central idea

If a traumatized patient positively influences and changes a situation that is externally similar to his trauma scene, it indicates that he has processed his trauma sufficiently. This is because he has developed the capacity to act in this special situation. As a result, by definition, the situation is no longer a retraumatizing situation (see Sect. 5.2).

The therapist supports the patient in integrating their inner transformation into the relationships in the present with the help of psychodramatic dialogue with role reversal (see Sect. 8.4.2), if necessary.

Case example 44 (2nd continuation, see Sect. 5.10.4)

The 35-year-old Ms. F. became more capable of dealing with conflicts in all her relationships after processing her trauma. This was the first time she really got to know the people in her social environment. People related to her had three different reactions: (1) The women from her women's group were grateful and relieved that she now openly expressed her wishes. In response to her coy request, it was the first time they joyfully took part in hosting the meetings in her house and even brought small gifts for her later. (2) Some work colleagues were ‘only’ pragmatic and searched for a solution to the conflict on the factual level. (3) However, Ms. F. had now recognized that three individual women were mostly selfish and inappropriately just asserting their own interests.

The therapist showed Ms. F. the technique of psychodramatic self-supervision (see Sect. 2.9): “You can save on some therapeutic sessions if you use this method at home alone!” The patient actually engaged in fictional psychodramatic dialogues with her ‘conflict partners’ at home. In doing so, she realized how different they thought and felt. For example, “sometimes they just hadn't thought about it”. At another time, their distancing from the other was ‘just self-protection’. However, Ms. F. also noticed that when she reversed roles and was in the role of the conflict partner, she often did not understand herself at all. She concluded: “I think I am not expressing my wishes clearly to others”.

Traumatized patients should also integrate their new understanding of themselves and their renewed self-worth into their relationship images concerning people from the past. This is because the development of the self is still blocked by defenses in old relationship images.

Central idea

The traumatized patient must dissolve his defense in the old relationships images from the past and free the development of his self-image and object-image in his inner relationship images from their fixation. Otherwise, if the old inner images are actualized in present-day conflicts, he will fall back into his old defensive patterns (Dieckmann, 1991, p. 25).

Therefore, the therapist leaves the patient as the adult he is now, to freely explore how he wants to understand himself and the partner in the relationship: “How did our relationship develop in our life? What do we mean to each other?” In this way, he gets to know his partner anew, as it were.

The integration of the new self-image into the old contents of the memory centers takes place in the following way: To begin with, the patient writes a fictitious letter to a person from his past (see Sect. 4.12 and case example 55 in Sect. 6.6). As an adult, the patient then shares with this person, in a psychodramatic dialogue with role reversal, how he now understands his childhood experiences differently. He says everything he always wanted to say and asks what he always wanted to ask.

Central idea

In the psychodramatic dialogue, the patient shares his inner subjective truth about his childhood with a significant person from childhood. But, by reversing roles, he also explores the reaction of ‘his conflict partner’ in the as-if mode of play and completes the internal psychosomatic resonance pattern in the conflict partner’s role (see Sect. 8.4.2). As a result, he knows how this person ticks. For example, by reversing roles with his sister’s role, he notices that she doesn’t want to know anything about his new truth. Instead, she distances herself from him so as not to breakdown herself. This experience helps the patient to perceive the sister realistically in the real encounter and to be mindful of her.

As a result, the patient develops additional interpersonal skills in real relationships with family members. For example, during role reversal, he notices that his “aunt” is interested in him and his thoughts. This motivates him to get in touch with his aunt again in real life. He may then speak to her about his childhood experiences and search for some family secrets. Even though in retrospect, at least now the patient receives compassion from this relative from childhood, along with some new information. These expand his self-image and his knowledge about the perpetrator from childhood. This strengthens his own position toward the perpetrator. It becomes easier for him to break free from destructive relationships with family members.

At the end of the therapy, trauma patients should also integrate their inner change into their relationship with their current partner or spouse. In long-term relationships, the first phase of love is usually followed by a phase of the ‘struggle for resources’. This also triggers some negative transferences. If the bond is strong enough, both partners can resolve these conflicts. However, this no longer succeeds once the couple has entered the stage of mutual neurotic allergy (Krüger, 2010b, see Sect. 8.4.3).

The only solution to a mutual neurotic allergy is that both partners inform each other about their own neurotic or traumatic wound in a calm way. Love then means developing compassion for the weakness of the other over time. Both partners should practice being mindful of the other's weaknesses without betraying their own inner child. The therapist can promote this development in the couple's relationship with the help of steps 6 and 7 of the psychodramatic dialogue (see Sect. 8.4.2). If an existing mutual neurotic allergy cannot be spoken of, this often leads to a separation or divorce (see case example 49 in Sect. 5.12).

5.12 Secondary Traumatization

Secondary traumatization occurs in childhood in relationships with traumatized parents or in the present in relationships with people with post-traumatic stress disorder. Psychotherapists can also experience secondary trauma by working with their trauma patients (see Sect. 5.16). Patients with relationship trauma in childhood have often been emotionally hurt by parents who themselves suffered from trauma-related disorders and, therefore, could not love their children, for example. These patients deal with their childhood conflicts through internalization (Hirsch, 2004, p. 1 f.). The traumatized parent remains present in the patient's soul as ‘a traumatic introject that floats around like a hostile, archaic superego’, causing symptoms, and pathological behavior.

Case example 48

Ms. G’s good therapeutic progress in her trauma therapy led to a dilemma: Her nocturnal psychosomatic complaints, fears, and sleep disturbances intensified when she allowed herself to be inappropriately controlled by her partner as before. Unfortunately, the patient reacted similarly with intensified symptoms when she newly asserted herself during the day and tried to make her relationships more equitable. Together, the therapist and the patient recognized that this was caused by the existence of an internal persistent pathological father introject. The patient’s father, traumatized as a soldier in the war, had been unable to allow closeness in family relationships. But he had determined the family relationships through his need for control and his sensitivity to conflicts in an authoritarian manner. Due to his inability to confront conflicts, he always appeared archaically threatening, even if he had never been physically violent. Her pathological father introject hindered the patient's emotional development in her adulthood as an internal hostile archaic superego.

The therapist and the patient together looked for ways in which the patient could regain the ability to act in the face of her threatening father introject. The therapist: “It is important that you allow each other a right to life. Your inner father should not want you, as his daughter, to break into pieces! And your inner father also has a right to life. Perhaps you have to use some transpersonal elements which are even more powerful than your father to appease your father”. Ms. G. invented the following procedure: In her imagination, she created a safe place by the sea for the nature-loving ‘father’, a place where he finds peace and quiet and gets what he needs: “The father should set up a home for himself in his safe place. But he is not allowed to enter my world. There is a hut for him in his safe place. Not far from the hut lives a wise older woman, a healer. The father can visit her in her house if he needs help”. Three days after this work, the patient could sleep through the night for the first time in a long time. She wrote a fictional letter to her long-dead father. In the letter, she ‘gifted’ her father the safe place by the sea as described. She announced that she wanted to give him back his suffering. She wanted to represent this symbolically by placing a small stone on his grave.

A fortnight later, a nocturnal dream helped the patient realize: “There are two ways I feel about my father now. I have a father who is threatening, but also someone else who is human and has his own story of life and suffering!” The patient slept well with some good and some bad nights over the next few weeks: “Sometimes I am overwhelmed with fear at night, and I have to fight through it again! It makes me angry that I am suffering! But the anger then helps me. The night before yesterday, I sent my real father away. But I imagined his threatening part was sitting on a chair in front of me. I then took a file folder and hit the chair with all my might. I killed the threatening part of my father. This got me out of my trauma film. I find that the negative image of my father is a ghost. I created the ghost myself as a child!” Afterward, the patient actually went to her father's grave. She had never been there after his funeral. As mentioned, she placed the stone of suffering on his grave. Half a year after this intense work, she was generally able to sleep well. Whenever she felt anxious at night, she imagined a new little episode of her ‘father’s experience’ in his safe place by the sea. In doing so, she moved him back to the other world and freed herself from him.

Central idea

People who were secondarily traumatized in childhood have often developed masochistic self-censorship through their spontaneous compassion for their father or mother. As a result, they cannot be angry with their inadequate parents. Empathy is a great human ability. Patients with secondary trauma, however, absorb the inner ‘ghosts’ of their traumatized parents into their own souls through their empathy. Because the family does not talk about the parents’ traumas, they cannot attribute the latent horror to the traumatized parent. They then consider themselves to be in the wrong and feel guilty. In such a case, the therapist and the patient work together to find solutions to appease the traumatized inner parent figure and return the suffering from their ’ghosts’ back to them.

Another patient with secondary traumatization re-enacted a memory from childhood in her therapy group: As a child, she stood in the dark, full of fear, with her teddy bear in her arms in front of her parent's bedroom door. She hears her war-traumatized father scream wildly. The mother tries to calm him down. In conversation with the therapist, the patient felt distressed and said: “He needs something from me to feel my love. But that can't be me! I can't and don't want to do that anymore!” To appease her father's pathological introject, the patient came up with the following solution: She decided to buy a teddy bear and let it participate in her life at home for several months. Along with her friend, she then wanted to bury him in her father's grave at night secretly.

To the therapist’s surprise, another patient wrote a coping fairy tale for her mother instead of her own coping tale (see Sect. 5.14): In this fictional story, the mother marries her childhood love in her young adulthood and is happy: “I had to let her be fine first. Before that, I couldn't find the way to my own wishful fantasies”. The pathological introject cannot be appeased therapeutically in a single session. It sometimes takes patients a few weeks before they find a coherent solution.

Secondary traumas also occur in current relationships with close people with post-traumatic stress disorder. This is the experience of women, for example, whose husbands were soldiers in the war or who suffered a serious illness and then developed PTSD. In the case of patients with secondary trauma, an ego split occurs between a loving ego state and a resigned, latently hating ego state. The two contrary ego states alternate with each other with a time delay in the relationship. The irresolvable contrast between love and fear or resignation is usually processed masochistically in a self-deprecating way.

In such a case, the therapist proceeds as follows: She lets the patient with secondary trauma engage in a fictitious psychodramatic dialogue with her traumatized ‘conflict partner’. However, the patient is caught between the desire to love and the need not to betray herself. Therefore, the therapist lets the patient represent her own internal self-image with two chairs, one for her ‘loving ego’ and one for her ‘resigned or hating ego’. The patient then initiates a psychodramatic dialogue between her two contrary self-images using role reversal. In doing so, the patient seeks a compromise between her two contrary ego states in the relationship with the traumatized conflict partner for the current situation.

Case example 49

A 35-year-old patient sought therapy because she had experienced violence in her childhood. Her partner treated her in an authoritarian and devaluing way as a result of his own childhood relationship trauma. The patient gave her partner a lot of chances. For example, she wrote him a ‘red letter’ asking him to discuss their relationship problems with her: “It's enough for me if we simply try to work this out together!” In response, the partner accused her of being ‘self-centered’. He never questioned his own actions. He never apologized. He never sought psychotherapeutic counseling himself. A year later, the patient secretly left their apartment for fear of his aggressiveness. She moved in with friends. But there, she suffered from severe sleep disturbances: “I'm brooding. I blame myself that maybe I haven't tried everything after all!”.

The therapist set up two chairs next to each other in the therapy room, one for the ‘loving Christa’ and one for the ‘resigned Christa’. He let the patient engage in a psychodramatic dialogue between these two ego states in the presence of the third empty chair for the partner. The therapist played the opposite role in each case. The patient accused ‘resigned Christa’ from the role of ‘loving Christa’: “You have failed! You should have adapted and remained content with what Uwe can give!” As an auxiliary ego in the role of ‘loving Christa’, the therapist experienced ‘a pull toward the partner like an addiction’. As ‘resigned Christa’, the patient explained to her ‘loving self’ the separation from her partner with the following arguments: “I can't stand it. I'm important too”. In identifying with the patient, the therapist sensed her inner distress. He gave role feedback and stated: “In my experience of you, it's not just about pleasure or displeasure. I am experiencing an existential need!” It is only now that the patient remembered the day on which she had first thought of separation. She had been massively debased by her partner in an argument. On her way back home, she seriously considered jumping onto the tracks before the next train when she was at the train station: “My partner has often behaved cruelly toward me. In doing so, he knew that his aggression triggers old fears from my childhood in me.” The therapist replied to the patient: “According to the United Nations Charter for Human Rights, you have the right to physical and mental integrity and your dignity as a person! These are absolute values. You can't put that into perspective! Existential values are different from arguments for wellness. Your suicidal fantasies indicate that: You must not ignore them! By the way, if you take your own life, the loving Christa would also be dead and no longer there for her husband!” At the end of the session, the patient in the role of ‘loving Christa’ gave herself permission to separate and said: “Otherwise the price is too high” (see continuation in Sect. 5.15).

5.13 The Natural Self-Healing System in Humans

Not everyone develops post-traumatic stress disorder after a potentially traumatic event. Hartmann (1996) substantiates this with an unconscious natural self-healing system in humans. He examined a series of nocturnal dreams of healthy people who had suffered acute trauma. He found that healthy people can process their psychological trauma with the help of their nocturnal dreams.

The natural self-healing system causes the dream work to go through the following steps when dreaming at night: (1) The traumatic event first appears in the dream images as it happened in real life. (2) The dream work shifts the emotion, for example, panic, through a change of scene into other images with emotionally related material. These can also be things that happened to other people in their childhood, for example, their brothers, sisters, or friends. Or they dream stories of animals or people from books. (3) A few weeks later, a woman who had been raped changed to the observer position witnessing another rape where she saw the victim being hurt in a dream: “I was walking down the street with a friend and her four-year-old daughter. Then a gang of male youths dressed in black leather came and began to attack the child. My friend ran away. I tried to free the child. But I noticed that my clothes were being torn off. I woke up in horror” (Hartmann, 1996, p. 3). The dream work let the real raped woman change from the victim role into a rescuer role in a situation that was similar to her own traumatic experience. That enabled her to act again and actively process the conflict in her dream in her internal image of the rape. (4) The dream work symbolizes the traumatic affect and event in an appropriate image. The feeling of being existentially threatened is depicted in the dream, for example, in the form of enormous, storm-lashed waves that flood the dreamer in a storm surge. Or the feeling of mental breakdown is symbolized in the dream by a house that collapses over the dreamer. (5) The patient’s guilt is also assigned to others in a dream.

The action in the dream results in the dreamer’s panic being linked to the various memory centers and developed into a holistic psychosomatic resonance pattern and then integrated with similar psychosomatic resonance patterns (see Sect. 2.7). Thus, according to Hartmann, the emotion gradually becomes less intense and changes its character. After a few weeks or months, the trauma plays an “increasingly […] smaller role in the nocturnal dreams of healthy people, and the dreams return to the pre-traumatic state” (Hartmann 1996, p. 5).

Many religious and social rituals activate people's natural internal self-healing system in crises. They improve the internal ability to act in frightening or potentially traumatizing situations through positive self-affirmation. For example, rituals at funerals, weddings, the baptism of children, when entering adulthood, after a master's examination, or after a state examination. Rituals embed fears and internal changes in the larger framework of human culture. The artistic creation of narratives, myths, literature, music, or the painting of pictures also invigorates the natural self-healing system and helps to process trauma. Mario Vargas Llosa, who in 2010 received the Nobel Prize for Literature as a Spanish-Peruvian writer, answered a relevant question: “Writing helped me face my life, all my disappointments, and failures. I think that's wonderful for an artist: you can use everything that goes wrong in your life and turn it into fiction. This is a great liberation” (Die Zeit, supplement, October 2011). The 12 steps of Alcoholics Anonymous also activate the unconscious natural self-healing system (see Sect. 10.7, Krüger, 2004, p. 184 f.). In the second of the twelve steps, they posit that there exists a healing system. But, they name this with the socially known and accepted symbol of ‘God’. In the next four steps, members establish a relationship with ‘God’, i.e., with their inner self-healing system that has not yet been sufficiently developed, and shape the relationship increasingly constructively. For example, they confess their faults to ‘God’ and ask him for help in their healing. Then comes the ingenious 11th step toward the end. Members ask ‘God’ to enable them to themselves do all that ‘God’ has done for them up to then. Thus, they ask him to make them capable of taking responsibility for their own healing. In doing so, they integrate ‘God’ or the inner natural self-healing system into their own soul. From the perspective of self-loss, self-empowerment, and self-healing, the 12 steps of Alcoholics Anonymous are an ingenious invention. They help people to activate and develop their natural self-healing system (see Sect. 10.7).

5.14 Coping Fairy Tales as a Technique for Trauma Processing

See Fig. 5.3.

Fig. 5.3

The Development of the Natural Self-Healing System through Trauma Therapy

Central idea

In trauma therapy, the therapeutic relationship and the doppelganger technique are, as it were, a holding container in which the traumatized patient re-develops his damaged or underdeveloped natural self-healing system (see Fig. 5.3).

As an implicit doppelganger, the therapist promotes the patient’s ability to switch back and forth between the trauma memory and self-stabilization autonomously. For this purpose, she uses (1) the method of coping fairy tales (Krüger 2013, Sáfrán and Csáky-Pallavicini, 2013) or (2) the Imagery Rehearsal Therapy (Krakow, Kellner, Pathak, Lambert, 1995). (3) According to Reddemann (1999, p. 90), the therapist lets the patient develop positive counter-images for negative emotional states. (4) The patient thinks of a concrete wishful scene that clarifies what he would have needed from the other person in the traumatizing situation instead.

Writing a coping fairy tale is a method of processing trauma. It helps to rewrite the trauma memory internally and to expand it with a healing fantasy of coping. A coping fairy tale has three sections, (1) the description of a traumatic event, (2) the fairytale-like transformation, and (3) the fulfillment of the wish or the actual longing. The fulfillment of the wish is described in concrete interaction sequences. In them, the large should become clear in the small.

The therapist proceeds with the practical work in the coping fairy tale as follows:

• 1. She recommends that the patient write a coping fairy tale for a single traumatic event.

• 2. She explains the concept to him by marking the three sections of the fairy tale with a stone each on the table stage: the traumatic event, the fairytale-like transformation, and the fulfillment of his longing.

• 3. She places an additional stone on the table for the patient's ego. She encourages him to always talk about himself in the third person when talking in the session and when writing the fairy tale at home, for example, ‘little Manfred who …’ or ‘little Renate who …’ (see case example 40 below).

• 4. The therapist and the patient determine the contrast between the actual feeling of suffering during the trauma experience and the fulfillment of the actual longing in the fairy tale: “What was the worst feeling? What would you have needed instead?”

• 5. Together with the therapist, the patient defines individual courses of action in his story. The therapist may play out the actions with symbols on the table stage, like playing with a doll's house. Together, the patient and the therapist look at the ‘coping fairy tale’ timeline on the table.

• 6. If necessary, the patient can begin the coping fairy tale by thinking of the wishful fantasy. That is all the more important in the case of a patient with a severe post-traumatic illness.

• 7. The therapist ensures that the patient does not harm himself by telling one story of suffering after another and regressing pathologically. She stops him if necessary: “Stop, let's look at this one traumatic event, please. More than one story will be too much for me.”

• 8. The patients develop the second part of the coping fairy tale, the fairytale-like transformation, usually only after the first and third parts of the fairy tale.

• 9. In the second part of the fairy tale, the little boy should not wait passively for his wish to be fulfilled. He should at least draw the attention of the ‘fairy godmother’ or other helpers or rescuers to himself with a small sign (Sáfrán & Csáky-Pallavicini, 2013, p. 276), for example, by crying. The patient learns through play that other people can react to him in a helpful way only when he no longer pretends as if nothing is wrong.

• 10. The patient writes the fairy tale little by little at home. This often takes him several weeks.

• 11. The therapist lets the patient show the final version of the fairy tale. She reads the text and suggests changes if necessary (see case example 40 below). The patient incorporates the suggestions into his coping fairy tale if necessary. The patient is not allowed to modify the fairy tale after the therapist has seen it for the last time. Otherwise, there is a risk that self-destructive patients may later change the coping part of their fairy tale into the opposite.

• 12. The patient reads the finished coping fairy tale again when he is in crisis in the future. The coping fairy tale then serves as a map for inner orientation. The first part of the fairy tale helps him recognize all that he has had enough of in his life and therefore does not need again. Then, while reading the third part of the fairy tale, he remembers what he actually longs for or needs in life.

Case example 40 (1st continuation, see Sect. 5.9)

A 40-year-old patient experienced a lot of violence in his family as a child. Toward the end of his therapy, he wrote a coping fairy tale. The fulfillment of his longing in the third part of the fairy tale involves him moving out of his violent parental home when he was 19. The therapist intervened: “But that is not a wish-fulfillment in the sense of a fairy tale! When did you leave home in reality?” The patient: “At 19 years of age”. The therapist encouraged the patient to look for a different solution for the fairy tale: “A wish-fulfillment at the age of 19 is too late. The little boy needs sufficient protection and love by the seventh or eighth year at the latest. Otherwise, it won't help him enough.” The patient rewrote the fairy tale. In the new fantasy story, “the teacher in his primary school class makes a home visit to his family. She recognizes the violence and notifies the youth welfare office. The youth welfare office brings the patient and his sister into a nice foster family.” Despite being a psychotherapist himself, the patient was amazed at the tremendous therapeutic effect this change had in his story: “I discovered something completely new for me. I didn't even know the as-if mode before. Now I know what people mean when they talk about making a wish!”.

In traumatized patients, the fulfillment of a wish in the coping fairy tale strengthens the process of self-development in traumatizing situations and frees it from fixation. The patient sometimes feels this change directly in his present life. One patient, for example, turned his abusive parents into ravens in his coping fairy tale. In the next group session, he said: “I have suddenly become more grippy in my everyday life. Earlier I used to think twice before saying anything. Now I notice that I respond to people quite spontaneously without thinking beforehand. I didn’t know I could do this myself.” Writing a coping fairy tale helps the patient develop self-empathy and justify their own feelings. In the coping fantasy, the patient allows himself to feel what he is feeling: When a child is sad, he is allowed to cry and is comforted. If he is afraid, he is hugged and experiences safety and security. If he is exposed to a chronically threatening, violent, or degrading situation, a good enough mother enters the threatening situation and fights to protect the child against the perpetrator. Or the mother and the child flee the violent situation and go to a safe place.

The lesser access a patient has to their own desires, the more difficult it is for them to write a coping fairy tale. In this case, the therapist must support him in small steps, which take 20 min each in several therapy sessions. The more a patient struggles, the more they learn. Working with the coping fairy tale is also diagnostically valuable. Patients who have not yet sufficiently processed their trauma usually do not complete the tasks when writing their coping fairy tale. For example, they put off writing their fairy tale for a long time or forget about it completely. Or they leave out a part of the fairy tale. A 50-year-old social worker, for example, ‘never got around’ to writing his coping fairy tale for more than a year. He then brought his ‘coping fairy tale’ with him in writing. The therapist read through it and was surprised. His fairy tale only consisted of the second part of the fairytale-like transformation. The patient explained to the therapist: “If I had written down a traumatic event from my childhood or the fulfillment of my longing, I would not have been able to work!” The patient wanted to move to another city three months later. The therapist discussed with him how he could stabilize himself in his new job and which retraumatizing situations he should avoid.

Sáfrán and Csáky-Pallavicini (2013) have successfully used the coping fairy tale method even in group therapy for patients with borderline personality organization. The method made it possible to proceed in a structured and disorder-specific manner. This stimulated the patient's introspection and self-empathy.

Trauma patients often suffer from nightmares. The sleep researchers Krakow et al. (1995) developed Imagery Rehearsal Therapy (IRT) for the treatment of chronic nightmares. The patients begin by writing down their nightmares. With the help of the therapist, they then complement the areas that trigger fear or stress with new, non-stressful content. The authors describe this procedure in a case example: The therapist gave the patient the task of keeping a dream diary for four weeks. The patient then had to find a new and positive turning point in each of her nightmares. She read these new, positive progressions for a quarter of an hour daily for a month and internalized them. “The occurrence of the nightmares reduced significantly after that, and so did the trauma symptoms such as depression or anxiety” (Die Zeit, No. 32, p. 28, August 4th, 2011). By rewriting their nightmares, the patients free their self-development from its traumatic fixation in their nightmares. They regain the ability to act in their fantasy. This generally promotes their ability to deal with internal conflicts.

Reddemann (1999, p. 90) activates the natural self-healing system by letting her traumatized patients develop positive counter-images to negative emotions: “It has become […] important for us to stimulate patients—if they are not doing it anyway—to find pictorial descriptions for their emotional states and sensitivities and then also their counter-images. For example, a patient might say that she feels ‘like she is in prison’. We would then suggest to her to see what a counter-image would look like and then invite her to let this counter-image work on her. In particular, to let it work on her body and to notice how her body is dealing with it. A counter-image could be, for example, ‘I feel like a bird’, and we could invite the patient to feel this, particularly in her body, and perhaps even move accordingly. Then we would recommend that every time she felt like she was in prison—and we would point out that this could be the case—she could evoke the counter-image, and we would explain to her that it is possible to oscillate back and forth between these two images and make it like a dance. […] Numerous interventions in everyday life, in dealing with everyday images and feelings, aim to create this pendulum movement, to create a feeling of counterbalance.” In this technique, the patient uses his negative feeling to develop a symbolic image. Then he looks for a positive counter-image for this negative image. After that, he notices how this positive counter-image changes his body perception. The patient can also represent the negative image and the positive counter-image with two chairs next to each other in the room and then change from his negative image to his positive counter-image externally. That makes the internal change easier.

Many traumatized patients complain about their attachment figures or their life situation without making any changes. Their masochistic self-censorship prevents them from developing concrete inner wishful thinking when in a conflict. In such a situation, the therapist proceeds as follows:

(1) She asks the patient: “How do you feel about your relationship with your wife in this situation? Why do you feel that?” (2) She continues: “What would you need in this situation instead?” (3) The patient thinks of a specific desired scene and describes what will happen in it step by step. (4) The therapist asks the patient: “And if your wish came true now, what would you feel?” A concrete inner wishful thought helps the patient orient himself internally in a conflict situation in everyday life. He knows what he needs and, therefore, remains capable of acting in his imagination in the current conflict situation in everyday life. This promotes his ability to deal with the conflict in reality and, for example, to say what he would like. Perhaps his inner wishful thinking is only fulfilled to ten percent in reality. However, this is more satisfying for the patient than if he just blindly acts out his masochistic inner images in relation to his conflict partner.

The therapist keeps working with the patient until the end of the therapy, to loosen the patient’s rigid defenses through grandiosity and masochistic self-censorship (see Sects. 4.10 and 8.5). This promotes the patient’s process of self-development in current conflicts. The therapist can point to the two chairs of the patient’s symptom scene in his everyday life (see Fig. 2.8 in Sect. 2.9) and invites him: “Just try to become a normal person.” The patient is usually baffled because he doesn’t even know what it’s like to be a normal person, a normal father, a normal husband, or a normal co-worker.

5.15 The Shaping of the Therapeutic Relationship

Patients with trauma-related disorders repeatedly pull their therapists into their defense processes. In this case, as an implicit doppelganger, the therapist unconsciously identifies with the patient’s self-protection through grandiosity and becomes a grandiose helper or savior herself. Or she identifies with his masochistic self-censorship and latently devalues the patient because of his self-debasement.

Case example 35 (continued, see Sect. 5.5)

A 42-year-old patient was violently abused by her father up to the age of 16. After inpatient treatment, she returns to outpatient psychotherapy and complains with tears in her eyes: “Before the treatment, I fought for survival every day. Now I'm even more exhausted.” She reports: “During the inpatient treatment, I felt unencumbered, free, and satisfied. I felt feminine and beautiful. There were ‘some sacred moments’. I re-enacted my key experience from when I was seven years old: I'm lying in bed, and there is thunder and lightning outside. I am afraid that Jesus will come and take my parents and sister with him. And then I'll be all alone. Our family belonged to a sect. My therapist let me act out this memory. In doing so, he let my ‘healthy adult’ perform. She should see what I need and then give it to me! However, besides me as a child, my ‘healthy adult’ herself was scared on the long way from my room to my parent's bedroom. Therefore, I needed the therapist to knock on my parent's bedroom door. As a child, I wanted to say to my parents: ‘Mom, Dad, it doesn't work like that. I need to talk to you.’ I had to force myself to open the door. I then switched to my ‘healthy adult’ role and said to my parents: ‘You mustn't continue to talk your daughter into believing that she is a bad child!’ After that, I was very proud of the ‘adult’ in me. The confrontation with my parents was important. In the role of the small child, I noticed: I no longer needed my parents! The little child preferred to return to his room with his ‘adult’. My parents didn't do anything in the play. As always, my mother was just a gray mouse! I felt quite alive after saying that aloud for once. I had the feeling: Yes, the ‘adult’ in me can protect me! I don't need my parents anymore!” Contrary to this statement, the patient is now sitting in front of her therapist in outpatient therapy in her hometown and is exhausted and depressed.

In this case example, the therapist in the clinic acted as a great helper and healer. He combined three different methods of trauma therapy in a single session, (1) the separation of the traumatized child from healthy adult thinking (see Sect. 4.7), (2) the trauma exposure through direct encounter with the perpetrator, the father (see Sect. 5.10.7), and (3) the integration of the inner change into the relationships with childhood caregivers (see Sect. 5.11).

Recommendation

Some patients had already been in trauma therapy once before they came to therapy. In such a case, the therapist assesses which of the seven phases of trauma therapy (see Sect. 5.6) the patient is in and proceeds with him to the next step in treatment.

The therapist let the patient in case example 35 act out her childhood trauma directly in the as-if mode of play without using self-stabilization techniques. In the traumatizing situation, she even had to think as a healthy adult and confront her parents as the perpetrators. However, she failed and panicked. The therapist, therefore, had to support the patient as a doppelganger. Thus, as a doppelganger, he created an emotionally corrective experience in the play and involved the patient in doing so. But, he didn’t resolve her defense through masochistic self-censorship. The patient wanted to preserve her new positive emotional experience after the hospital stay. But, she could only do it in the relationship with her therapist. Unfortunately, she could not take her therapist home with her. The loss of the helpful relationship with her therapist in the clinic triggered her old traumatic experience of abandonment from childhood and she decompensated into depression.

Trauma experiences have an existential quality due to encounters with basic human fears (see Sect. 5.9). The therapist, therefore, meets the traumatized patient also as a human (see Sect. 4.13). She makes statements and rarely asks questions. She also justifies her own feelings in the here and now. As an implicit doppelganger, she identifies with the patient’s inner self-development in the current situation. But then, without noticing it, she gets caught up in the patient’s split-off affect and physical sensations. In psychoanalysis, this phenomenon is described as defense through ‘projective identification’ (see Sects. 2.4.4 and 4.15). According to König (1984, quoted from Heigl-Evers, Heigl, et al., 1997, p. 351), the therapist becomes similar to the parts of the self transferred from the patient through ‘unconscious manipulation’.

Central idea

When interacting with a traumatized patient, the therapist often feels helpless, powerless, overworked, angry, nauseous, dizzy, or fearful. These feelings mostly do not express their therapeutic inexperience. For example, their anger is often not anger toward the patient but rather the patient’s split-off anger. Likewise, their fear is often not the fear of the patient but the fear split off from the patient. In identifying with the patient’s self-development in the therapeutic relationship, the therapist senses in herself, without consciously noticing it, what the patient does not allow himself to feel through his defense.

Case example 49 (see Sect. 5.12, continued)

A 40-year-old, self-confident patient was physically abused in childhood. She worked on her coping fairy tale in her eighth therapy session (see Sect. 5.14). She narrated a traumatic event reflecting her suffering: Little Brigitte was supposed to nap in her room. Suddenly she urgently needed to go to the toilet. But she was not allowed to do this because she would have had to disturb her mother in her afternoon rest. Otherwise, her mother threatened to hit her and not talk to her anymore. The little girl tried very hard not to get wet for one hour. The therapist: “What would the little girl actually have needed in this situation?” This gave rise to a little fantasy story with a ‘good enough mother’.

In the further course of the session, the patient then narrated other traumatizing experiences from her childhood. She described how she had been beaten by her father, her classmates, as well as her grandfather and said with resignation: “Everyone was allowed to hit me!” The therapist realized too late that he was being drawn into the patient's states of affliction through his empathy. He found himself feeling sick. He was already acquainted with this sickness. Nausea always made him aware that he took on too much in the relationship with a traumatized patient.

The therapist, therefore, mindfully interrupted the patient and said: “This is too much for me. I feel a bit sick. It is unbelievable how strong you had to be. You endured and survived everything in your childhood and youth. As a child, you had to turn off your feelings. You simply had to focus on functioning. Otherwise, you would have upset your father and mother even more”. The therapist got up and grabbed an empty chair: “I'll place a chair over here next to you for your perfect functioning as a child, for your self-protection behavior”. He took a second empty chair and positioned it in the far corner of the therapy room: “This other chair here is for the traumatized child in you who experienced the traumatizing events”. The therapist sat down on his own chair again: “Now let's first look for a positive counter-fantasy, for a ‘safe place’. I need this for myself so that I can feel better again. The ‘safe place’ technique is a self-stabilizing technique. It will help you to leave the therapy room in good shape after the session!”.

Central idea

In trauma therapy, the therapist unconsciously becomes a metacognitive doppelganger in the patient’s self-development. She needs to develop ego control over her work as a metacognitive doppelganger and harness her own feelings and physical sensations for therapy.

Gabi Tarda (only orally communicated 2019) summed up her experience in the role of the patient in a trauma seminar with the following words: “As a patient if I experience that the therapist does not want to help, but becomes my doppelganger, in some sense I remain alone, but I am not really. The accompaniment of the therapist as a doppelganger increases my own feeling of competence”.

As a metacognitive doppelganger, the therapist uses the following methods:

• 1. If she thinks her emotion is part of the patient's trauma experience, she tells the patient how she feels as an encountering human being (see Sect. 4.13). Patients with trauma-related disorders need a person who can testify as a witness to the truth of their ‘trauma’ (see Sect. 5.5). They need the compassion of a person who senses the existential quality of their emotional injury. This is an essential impact factor in trauma therapy.

• 2. Central idea

  The therapist and patient retrace the path of the patient’s defense through projective identification. The therapist makes his dominant defense pattern, which triggers her affect and body awareness, the object of therapeutic communication and represents it externally as a chair in the room. Thus, the patient himself goes into the opposite role of his defense pattern and feels what the therapist felt. The interpersonal acting out of the conflict becomes the patient’s intrapsychic conflict again. The therapist proceeds by using chair work with the patient’s metacognitive ego states (see Sect. 4.8).

• 3. The therapist uses psychodramatic responding, if necessary (see Sect. 4.13). For example, she will set up an empty chair next to her for herself as an ‘expert therapist’. This makes her and the patient feel internally secure. It stabilizes her in her role as the ‘encountering human being’.

The appropriate management of the therapeutic relationship is critical in the therapy of acutely traumatized people, for example, in the relationship with refugees with post-traumatic stress disorder. The therapist first helps such a patient to resolve his acute dissociation and to attenuate his overactivity. This is the prerequisite for regaining interest in his environment and himself and being able to act again in his own life (Bakhit, 2006, p. 304). Therapeutic work with refugees must take place in a protected setting where the patient has control over what is happening. In refugee shelters, the destruction of the patient's internal ego structures must first be compensated for by a secure external framework. The therapist informs the patient that she will respect her confidentiality. She adheres to the agreed working hours. The door of the counseling room must not be opened again and again. Victims of torture, need a stable, safe social environment as a prerequisite for effective trauma therapy. In such a case, the therapist intervenes as a real doppelganger in the patient's real social environment. For example, she accompanies him on his visits to the public authorities.

In the therapy of traumatized refugees, the therapist shapes the therapeutic relationship (Bakhit, 2006, p. 310). Together with the patient, she develops a ‘safe place’ with the help of stones, wooden blocks, or other objects that the therapist has brought along (see Sect. 5.10.5). Among other things, she also represents the patient's abilities and resources. The actual trauma processing takes place with the help of the table stage (see Sect. 5.10.10). The therapist is a kind of container for the relationship throughout therapy. She creates trust through attention, appreciation, interest, and active relationship building. Thus, she becomes a catalyst for the thawing and integration of the frozen internal emotional processes of the patient. In doing so, the therapist, as a metacognitive doppelganger, vicariously experiences his split-off emotions and physical sensations and has to endure them: bewilderment, shame, powerlessness, feelings of guilt, helplessness, feelings of loss, loneliness, numbness, or emotional rigidity. She names the feelings keeping in line with ‘the principle of response instead of interpretation’ (Heigl-Evers, Heigl, Ott and Rüger, 1997, p. 176ff., see Sect. 4.13): “I notice how I freeze internally and feel paralyzed when I imagine the horror you have had to experience. I think I'm feeling something of what you have felt!” Bakhit (2006, p. 315) recommends: The therapist must “endure and withstand the feelings”. She should refrain from appealing for encouragement. Instead, she appreciates the existential quality of his traumatic experiences. After some time, the patient’s life-affirming ideas will set in again as if by themselves.

5.16 Secondary Trauma and Burnout in Therapists

Central idea

Therapists should be careful with their own resilience when conducting trauma therapy. Time and again, they should activate their own physical, psychological, and social resources through appropriate exercises. In doing so, they resolve the blocks in their internal self-development adopted from the patient. This is a prerequisite for their therapeutic abilities to be freely and entirely available to them.

Case example 45 (4th continuation, see Sects. 5.10.5, 5.10.6, 5.10.7, and 5.10.8)

Ms. D.‘s trauma exposure session lasted more than three hours. It was about a life-threatening rape attempt. After leaving his practice in the evening, the therapist noticed that he was looking down the street in both directions when he locked the door. He was afraid that a violent criminal might suddenly attack him. The therapist wondered about this himself. He didn't know himself to be so cautious and afraid. He realized: He had the same fear of darkness that the patient had suffered from before in her trauma exposure session. He was worried. The next morning he remembered: During her trauma exposure session, Ms. D. had given ‘Saint George’ a wooden sword in hand when in her ‘safe place’. The assistant therapist who had played the saint's role had not used the sword. The therapist used this idea for himself. In a second new trauma exposure session, he imagined the protagonist would represent the perpetrator on a chair using a large vertical foam cushion. The patient would then pierce the ‘perpetrator’ with her sword in a state of rage. The therapist wanted to check with his sword whether the patient’s stab was strong enough for the sword to come out of the pillow on the other side. The therapist noticed with astonishment: This fantasy act transformed his internal image of the perpetrator. Until then, the perpetrator had been a terrifying ghost to him. But stabbing made him a living person made of flesh and blood, capable of suffering. The therapist's fear of darkness disappeared after this inner work. It never reappeared.

Central idea

Some of the therapist’s own physical or emotional reactions may be feelings or sensations that the patient has not yet dealt with sufficiently in trauma processing. In such a case, the therapist, as an implicit doppelganger, tries to vicariously integrate the affect delegated to her by the patient into his trauma processing and to think through it to the end in as-if mode. In doing so, she gives herself every freedom in her fantasy. She may later communicate the result of this vicarious trauma processing to the patient as a sharing in a digested form.

The following methods protect the therapist from secondary traumatization:

• 1. The therapist also develops a ‘safe place’ for herself and visits it when necessary.

• 2. In therapy sessions, she internally names even her own feelings for herself. In doing so, she internally separates herself from her patient and resolves her defense through introjection (see Sects. 2.4.1 and 2.4.4).

• 3. She works ‘only’ with a limited number of patients with trauma-related disorders so that she herself does not ‘break down’. This is because trauma therapy work exhausts and triggers therapists’ own conflicts and traumas.

• 4. Supervision or intervision relieves the therapist’s soul and gives her a new perspective on the therapeutic relationship if needed.

• 5. The therapist’s own conflicts being activated in therapy should be an impetus to develop herself further internally and, for example, to look for answers to existential questions. For this reason, many therapists withdraw once a year to a place where they can develop new internal images and skills together with others. They open up to transpersonal experiences through meditation or get help if necessary to deal with their own conflicts. Again, it’s about staying true to their own self in motion internally. Otherwise, there is a risk of developing a rigid defense system over time.

• 6. If necessary, therapists also seek therapy themselves.

Too much compassion can lead to secondary trauma or burnout in therapists. On the other hand, therapists who have experienced trauma and have been able to process them adequately in their own therapy, know precisely what their patient is talking about and are a good resonance body for the existential quality of trauma experiences. However, there is also a risk that they will overwhelm themselves as helpers and rescuers.

Case example 50

A 40-year-old patient was treated in a hospital for a long time in her third year of life. Her behavior afterward became ‘difficult’ for her family. As an adult woman, she worked as a psychotherapist in a psychosomatic clinic. There she was known for her big heart for patients with severe relational difficulties and destructive tendencies. Because she consistently protested against disciplinary measures imposed on them. She then skillfully explained to her colleagues the psychodynamic reasons for the cross-border behavior of these patients. However, the consequence of her justified protests was that she often had to treat the most challenging patients herself. And she regularly had more patients to look after than her colleagues. Three years later, she left the clinic because of impending burnout.

Central idea

Therapists who have experienced trauma themselves consider their own compassion for the traumatized patient to be ‘normal’. In group dynamics, however, they end up in the omega position of their team (see Sect. 2.11) if they unilaterally insist on pushing through their existential truth. The team members develop an opaque mix of negative transferences and countertransferences. This results in destructive team conflicts.

The clinical team should always recognize the protests of therapists with traumatic experiences as complementary truths. However, the high demands of therapists with trauma experiences must not overburden the team and the clinic. They need to be integrated into the reality of the clinic.

5.17 Concepts of Psychodramatic Trauma Therapy by Other Psychodramatists

Nineteen psychodrama therapists from nine countries have described their own experiences with psychodramatic trauma therapy in the book ‘Psychodrama with Trauma Survivors’ (Kellermann & Hudgins, 2000). I summarize the most important contributions below.

In the case examples mentioned in the book, after the end of their therapy, patients repeatedly emphasized that acting was more healing than talking. Previous purely verbal therapies had not helped them (Kellermann & Hudgins, 2000, pp. 78, 86, 221). Kellermann (2000, p. 14) points out that trauma processing often requires more than just a single psychodrama play: “As most clinicians and researchers believe these days, for full healing to occur, the core trauma must often be revisited to release dissociated emotions and change trauma-based cognitions”. The setting of group therapy has a special meaning in psychodramatic trauma therapy (Karp, 2000, p. 69 ff.; Kellermann, 2000, p. 33; Roine, 2000, pp. 83–91; Baim, 2000, pp. 165 ff.; Hudgins, 2000, p. 236 ff.; Burmeister, 2000, p. 218 ff.). Because the other group members witness the protagonist’s trauma as ‘Trauma’ (Dayton, 2000, p. 119 f.). They offer intensive care through their sharing (Kellermann & Hudgins, 2000, pp. 67, 177, 194, 196, 218) and thus help to reduce guilt and shame. On behalf of all other people, they take the protagonist back into the human community through their testimony, participation in the protagonist-centered play, and sharing. Nevertheless, many psychodrama therapists also work individually (Burge, 2000, pp. 299–316; Burmeister, 2000, pp. 198–223; Roine, 2000, pp. 90, 92). Bannister (2000, p. 101) initially uses individual therapy in the therapy of severely abused children and only later used group therapy.

5.17.1 Peter Felix Kellermann (2000, pp. 23–40): The Therapeutic Aspects of Psychodrama with Traumatized People

As an experienced trauma therapist, Kellermann (2000, p. 26) emphasizes: (1) Trauma therapy requires the re-enactment of the trauma scene. (2) But unprofessional re-enactment of the trauma scene poses the risk of retraumatization. (3) Traumatized people easily mislead inexperienced therapists into evading the crucial traumatizing situation. Because traumatized patients have a ‘strong need for gentleness’. (4) Trauma work needs reliability, support, and safety (see Roine, 2000, pp. 88, 93, 95). (5) The therapist should prepare the patient very well. Before starting with the play, he must discuss every step of the process with the patient and obtain his consent.

Kellermann (2000, p. 26f.) divides psychodramatic trauma processing into six steps. Each step is therapeutically effective even when practiced on its own:

• 1. The re-enactment of trauma in a safe environment: A young girl (Kellermann, 2000, p. 27 f.) had lost her mother in a tragic car accident. She re-enacted the traumatizing scene over and over again. Kellermann thinks that protagonists sometimes have to repeat a trauma scene seemingly endlessly. This is because when the group participates and echos their feelings, it helps them confirm that they are feeling what they feel. “Getting the traumatic experiences out into the open is in itself a liberation from the earlier tendency to repress the emotional impact of the event.” Showing the traumatic experience in public can help the protagonist reduce the event's emotional impact and gain control over the emotional response to the trauma.

• 2. The cognitive processing: A man complained of recurrent flashbacks from the terrible scene of terrorist bomb attacks (Kellermann, 2000, p. 29 f.). His everyday life seemed like a dream or a movie to him. Kellermann asked the group members to translate the terrorist attack into a role play. The director asked the protagonist to look at what was happening in the play from a meta-perspective. This helps acutely traumatized patients to develop their linguistic concepts and thinking in the psychosomatic resonance circuit of trauma memory (see Sect. 2.7) into a holistic ‘personal history’ of what happened. As a result, they resolve their dissociation in conflict processing.

• 3. The emotional catharsis: Kellermann (2000, p. 30) narrates a case example: As a child, “a patient overheard his alcoholic father fight with his mother during the night’. He had asked his parents to be quiet, but he had been hit and reprimanded in a humiliating manner. He had then been sent to bed”. The patient re-enacted the childhood scene. When he was ‘alone in his bed’, he began to sob. The director urged him to ‘let go and let his body do what it needed to do’. The patient cried harder. His crying didn't seem to end. Ultimately the tears stopped, but his body went into spasms, convulsing with the hiccupy gasps and shudders that are the aftermath of heavy crying. ‘I am going to throw up’, he whispered. Someone brought a bucket to let him cleanse his stomach of the disgust that he had kept within him for so long. He lay still for a while and then expressed his feelings toward his parents in words. As a closure, a different father held him until he calmed down sufficiently to return to the group. Kellermann says: “… the symptoms of trauma are the result of a highly activated incomplete biological response to threat, frozen in time. Trauma can be healed by enabling this frozen response to thaw and then complete itself.” According to Kellermann, it is crucial that “catharsis is neither induced, nor inhibited, but allowed to emerge in its own time and form.”

• 4. Elements of Surplus Reality: A Vietnam veteran was obsessed with guilt for killing his friend (Kellermann, 2000, p. 31 f.). He had watched, from a hiding place, as a wounded friend was captured and later shot. The patient wished that he had the courage ‘to do to himself what he had done to his friend’. Following this re-enactment of what had happened in the past, the director suggested that the protagonist enact what had never happened but what he would have liked to happen. A group member took on the friend role, and the protagonist then saved his ‘friend’ in the play. He did this against all orders and all reason. “He put him in a safe place. When holding his friend, … he started to cry for his friend as if for the first time.” When the protagonist had calmed down, the group member in the role of his friend spontaneously said: “It was not your fault that I died. You were my friend. I know that you did the right thing. If you had tried to rescue me, we both would have died. I desire that you will now live for both of us”. Kellermann (2000, p. 31) says: If the protagonist experiences shame and guilt, it is important to let him rehearse the better and alternate possibilities of action in the trauma event using surplus reality in the play. This helps with trauma processing. In trauma therapy, the therapist should also always let the protagonist ‘undo what was done and do what needs to be done’ in the psychodramatic play.

• 5. Repairing old relationship experiences through group therapy (Kellermann, 2000, p. 32f.): The therapist encouraged ‘an obese and unhappy woman, who had been abused and neglected as a child,’ to stage some specific scenes of her childhood abuse in group therapy. At the end of the play, ‘she suddenly became very likable and attractive’ as a lost child in a chaotic universe. The group noticed her new inner beauty. A ray of sunlight accidentally shone on her through the window of the group room. The group celebrated this change with a ritual: ‘It was as if the patient were born again.’ “Adults who have survived abuse as children are especially amenable to some kind of corrective interpersonal learning experience to counteract their impaired sense of trust, security and ‘belonging to the human race’. They experience a new sense of safety and intimacy.” They are re-integrated into the human community, thereby improving their self-esteem.

• 6. Therapeutic rituals (Kellermann, 2000, p. 35 f.): Traumatic events sometimes affect a whole community. In such a situation, the therapist invites the group members to participate in a crisis intervention session with collective sociodrama. For example, Kellermann worked therapeutically with the surviving employees of an institution six months after multiple murders. He used an old Indian ritual called the ‘talking stick’. This stick “is passed around the group, allowing each person holding the object to say whatever they want. Other group members remain quiet but may say ‘Hau!’ if they agree with what has been said.” Using such universal principles of ‘Mother Nature’ as well as symbols and stories from mythology helps in thawing the frozen emotions. The stories make it easier for the therapist to grasp the group topic and then continue working in a protagonist-centered manner. In the case example, one of the employees, as the protagonist on stage, expressed her feelings of grief and yearning for one of the ‘victims’. She also did this on behalf of the other employees without intending to do so. As a result, the other group members could share their own experiences and thus dissolve their own emotional blockages.

5.17.2 Marcia Karp (2000, pp. 63–82): Psychodrama of Rape and Torture: A Sixteen-Year Follow-Up Case Study

Karp describes in detail the treatment of a 48-year-old woman with trauma. The patient Jill, along with her husband and daughter, was attacked and raped by eight men in Africa. Jill was an independent woman with a strong personality. After the traumatic event, she organized the necessary medical care for the family as well as their return trip from Africa to England, all on her own. However, she fell into a chronic dissociative state for two years afterward. She was being ‘completely submissive like she is a nobody’ (Karp, 2000, p. 75). She received outpatient and inpatient psychiatric treatment and was prescribed strong psychotropic drugs. Despite the treatment, she remained depressed and could not leave the house.

Karp successfully treated the patient in just one preparatory individual session and two group weekends four weeks apart. The group members began by re-enacting the patient's fictional ruminations and self-accusations in the playback process: “If I had done that, it would have turned out differently.” “If I had hidden my daughter, my husband, or the dogs shot by the perpetrators, then […]”. The enactment of the many ‘ifs’ made the protagonist realize that the retrospectively devised alternative courses of action would have been in vain: “Implicit but not verbalized, it became clear that if Jill had resisted in any scene, she would have been killed on the spot.” Subsequently, the group members enacted the patient's trauma on the stage by following the instructions of the therapist and the protagonist. The protagonist unraveled the events and the sequence of the entire trauma event for the first time in the three-hour trauma exposure session. She directed the play from the narrative and observation space and completed her fragmented memories. She took on only the role of another family member in the trauma scene. That was the role of her 17-year-old daughter. In this role, she discovered that the most important thing for her ‘daughter’ was that her mother did not endanger herself through her behavior and die. The ‘daughter’ didn't expect anything else, even though she had been raped. It was only in the role of her daughter that the protagonist realized that as a mother, she had saved her daughter's and her own life with her presence of mind. When the ‘perpetrators’ left the room for a short time, she and her daughter immediately fled.

During the trauma exposure session, the protagonist moved only once from the narrative room to her own role in the interaction room of the trauma event. The ‘perpetrators had already left’. Unlike in the real past, she said goodbye to her ‘employees’ in Africa in the play. In doing this, she began to tremble uncontrollably. The patient’s state of dissociative shock resolved. The therapist and the group ensured a safe and stable environment. The husband had accompanied the patient to therapy. He was there for her after the trauma exposure session at their shared hotel. The patient had experienced severe sleep disturbances before the psychodramatic trauma processing. However, after releasing her sensorimotor blocks, she slept for 30 h straight.

During the violent attack, the perpetrators told the patient that her daughter and husband were dead. In the traumatizing situation, the patient had split off her sensorimotor interaction patterns, physical sensations, and affect through dissociation. As a result, she couldn’t feel the presence of her attachment figures. It was only after processing her trauma that she felt emotionally reassured that her husband and daughter had survived. She also realized that she had ‘been out of control’ during the trauma event but had not remained passive. In fact, she had acted extremely wisely and appropriately. The group members and the therapist attested to this fact. As a result, her feelings of shame and guilt had now disappeared. According to Karp, shame and guilt are often heavy burdens for rape victims.

5.17.3 Eva Roine (2000, pp. 83–96): The Use of Psychodrama with Trauma Victims

Roine describes four case examples: (1) the therapy of a woman whose uncle sexually abused her as a girl, (2) the treatment of a man whose uncle raped him as a 10-year-old boy, (3) the treatment of a traumatized pedophile man, and (4) the therapy of a torture victim. Roine believes that freedom from trauma must be through action. “By reconstructing the traumatic events in psychodrama, the protagonist is encouraged to control the situation in a new manner.” The protagonist can only gain the necessary control over the situation through acting (Roine, 2000, pp. 86, 94). The energy frozen in the state of helplessness becomes accessible through action. If the protagonist is at risk of getting stuck halfway, the therapist should lead him directly to the ‘heart of trauma’. Roine quotes Ildri Ginn, the director of the Boston Psychodrama Institute, who said: “When treating such patients, it is more dangerous to stop halfway than to go the whole way” (Roine, 2000, p. 88). “The director must have the courage to touch the emotional core of the subject” (Roine, 2000, p. 95). “Unsuccessful attempts can fixate the protagonist in trauma” (Roine, 2000, p. 93). Roine (2000, p. 88) emphasizes: “If the therapists have not understood and experienced the traumas of their own lives, they will not dare to descend into the depths of the patient's pain either.”

5.17.4 Anne Bannister (2000, pp. 97–113): Prisoners of the Family: Psychodrama with Abused Children

Bannister describes the psychodrama work with severely sexually abused eight to nine-year-old boys and girls based on twenty years of experience. Traumatic events destroy a child’s ability to relate. Therefore, before the beginning of the six-month group therapy, traumatized children remain in individual therapy ‘until they ‘have had the opportunity to form an attachment with at least one non-abusing adult’ (Bannister, 2000, p. 101). The therapist promotes the development of the children through symbolic games or direct re-enactment of trauma experiences (Bannister, 2000, p. 102). In doing this, Bannister integrates psychodrama therapy, puppetry, working with sound, painting, and music into creative play therapy. These media help the children gain spontaneous access to elements of their trauma history and develop new solutions that promote their self-confidence and self-control. Children find it particularly difficult to ascribe appropriate meaning to their experiences of abuse. Therefore, they must directly learn the meaning of their traumatization in a safe environment through symbolic games.

Bannister (2000, p. 105 ff.) structures individual group sessions as follows: (1) At the beginning of each session, the children play the warm-up game, the ‘wolf’ tries to catch the ‘sheep’, with hand puppets. The game varies over time. They define specific rules, such as the rule that there are specific ‘safe places’ which cannot be invaded by the wolf. (2) Children were invited to tell how the puppets from the previous game felt in the here and now. (3) A break for refreshment follows. (4) Then comes the actual play phase. The children work with clay, paint, play with hand puppets, or dress up and do a role play. (5) All of them together speak the group slogan the therapist gave and act on it: “I'm a good person, I'm proud of me, I've been through a lot, look how strong I've got!” (6) During debrief, the children throw a ball to another group member. They thank that person for something they had appreciated during the session.

There are some peculiarities in Bannister's approach: The therapist-patient interaction is one-to-one, even in the group. The therapist works with a variety of materials. She also lets the children play a lot with hand puppets in group therapy. According to Bannister (2000, p. 103), “the use of puppets is often recommended with children… It may be that this form of projection helps to distance the action”. Children with severe abuse also tend to attribute magical powers to perpetrators. The diminished size of the characters as hand puppets makes the play easier for the children to control. The group therapy developed by Bannister is a laborious and time-consuming process. However, scientific studies prove that severely disturbed children develop positively in therapy. Their self-confidence increases, and their self-control improves.

5.17.5 Clark Baim (2000, pp. 155–175): Time’s Distorted Mirror: Trauma Work with Adult Male Sex Offenders

Baim reports on trauma therapy for adult sex offenders. His work is based on the conviction that in most cases, sexual violence is a symptom of illness, a symptom of the perpetrator's maladaptive thinking, feeling, and behavior patterns developed largely in response to their own earlier trauma (Baim, 2000, p 157). Various studies have shown: 18–93% of violent sexual offenders were themselves sexually abused in childhood or were beaten or neglected in an extremely brutal way. But that was never addressed in childhood or later. Therefore, the patients themselves never attached any importance to the trauma. The trauma experiences of these patients remain unprocessed in the memory through dissociation and are stored on the sensorimotor level. The limbic system, which is responsible for emotional regulation and the ability to bond, is 20–30% smaller in children with a history of abuse as compared to other children (Baim, 2000, p. 160). This is why even the slightest stress leads to overreactions and loss of self-control in people with trauma. For this reason, many trauma survivors get used to avoiding feelings altogether. However, this makes them emotionally numb.

According to Baim, most offenders do understand on a cognitive level, even at the time of their offending, that what they are doing is wrong. However, they cannot control their emotions because of their altered brain functions. It is, therefore, superfluous to cognitively teach perpetrators of violence why sexual violence is wrong because it does not change their psychophysical dysregulation. At present, the treatment of sex offenders is dominated by the cognitive behavioral approach. However, according to Baim (2000, p. 163), “they have been compliant in treatment, learned to ‘talk the talk’ … and managed to show improvements in psychometric tests—only to go on to later re-offend”. Based on these considerations, Baim concludes: Some of the perpetrators commit the act of violence in equivalence mode in a kind of trance state. The victims are fixed in their perception of the act of violence in a perpetrator-victim schema. Feelings of helplessness or powerlessness trigger a kind of suction in them, resulting in a flashback. For this, it is enough that the affected person meets a fearful, powerless person who is just the way he used to be. That is unbearable for him. He hates himself in the other because of his weakness. When he can no longer stand being a victim, his only choice is to become an offender. He reverses the victim-perpetrator roles and acts out his hatred in the role of the powerful perpetrator. The trance state dissolves as soon as the act is finished. At some point, he thinks as a healthy adult again and realizes on his own that he has been violent and hurt another person.

According to Baim (2000, p. 164), one is guilty of malpractice if one does not treat a disease causally after knowing the root cause of the disease. He suggests supplementing cognitive behavioral therapy with trauma therapy. Trauma therapy should reduce the energetic potential of the cycle of violence. Patients have to emotionally process their own trauma experiences from their childhood. This is because, as perpetrators, they can only develop the desired empathy for their victims by gaining empathy for themselves as trauma victims in therapy. They should learn to stop hating the child they once were.

Baim likes to work with contrasting images. For example, he lets the patients set up two sculptures as a warm-up exercise: one of a family where anger and fear are always present and another with images of a hypothetical family that communicates well and supports each other. The group members can intervene in the symbol work and change it. In doing so, they learn what is helpful and harmful for children. They recognize connections to their own behavior as an adult and also as a child.

In any case, patients should go through the following steps in psychodrama therapy (Baim, 2000, p. 166): (1) A conversation between me as a victim of abuse and those who perpetrated against me; (2) A conversation between me as a perpetrator of abuse, and those who perpetrated against me; (3) A conversation between me as a victim of abuse, and the victims I have perpetrated against; (4) A conversation between me as a perpetrator and the victims I have abused.

In Baim's experience, the most powerful key to the underlying childhood trauma lies in the role of the perpetrator. Therefore, he first lets the patient therapeutically process his own act of violence as the perpetrator. The patient should cognitively grasp his role as a perpetrator. Next, the therapist works out a ‘violence circle’ with him in writing. The perpetrator develops an idea of how to break this circle. Baim consequently structures the psychodramatic work that follows. Thus, he wants to prevent the patient from dissociating when enacting his own perpetrator role. (1) The patient symbolically represents his intrapsychic strengths and a transpersonal contact person with whom he can interact on stage. (2) A supportive doppelganger accompanies the patient throughout the entire play. (3) An auxiliary ego takes on the role of the perpetrator in the scene as a doppelganger. (4) The protagonist shares his thoughts, feelings, and behavior during the act of violence from the observation and narrative room (5) He describes the place where the act of violence took place and defines his own position and actions in this place. (6) The protagonist uses a symbol for ‘the scene of the crime’ to mark where he was during his crime. (7) He repeats the words he used then but still stands outside the scene. (8) It is only after that, that he takes on his own role in the trauma scene and re-enacts it. (9) In doing so, he repeatedly swaps roles with his previously defined internal and external stabilizing auxiliary ego as well as with his victim. According to Baim, this reduces the emotional dynamic in the perpetrator role and stabilizes the patient internally. (10) Baim lets the perpetrator play the role of a fictional ‘Mr. Self-Aware’. This is the role of a fictional ex-offender who has successfully completed the therapy program. This “ex-offender” is now able to abide by the law and has not relapsed.

Baim's approach to coping with the offender's childhood trauma is very similar to that of coping with his crime. He describes this using a case example: His patient Adrian had continuously sexually abused a girl who was related to him between the ages of 9 and 11. To process his childhood trauma, Baim asks his patient to symbolically represent on stage: (1) His ability to care for others, his ability to listen, and so on. (2) A good mother. Unlike his mother, the good mother actively intervenes and protects him as a child from his father. His father had previously abused him brutally. (3) A group member plays the role of the transpersonal protective figure Martin Luther King. (4) A doppelganger accompanies the patient till the very end. (5) Two auxiliary therapists re-enact the father's abuse. The therapist, the client, as well as the group members, observe the actions of the brutal father from the narrative room. They name the incident as ‘unbelievable violence’. (6) The protagonist then meets his fictional helpful, good mother. This results in an emotional catharsis. (7) The patient also takes on his own role as a victim once in the interaction space of the trauma scene. This brings the abuse to life even in his sensorimotor system. However, unlike before, this happens in a new ‘holding way’. In the middle of the scene of violence, the new, strong, and just mother saves the 8-year-old boy. The patient reacts with another intense emotional catharsis. Baim followed his patient Adrian’s career for more than a year after his release on probation. During this time, the patient continued to develop positively, made further progress, and did not relapse.

5.17.6 Jörg Burmeister (2000, pp. 198–225): Psychodrama with Survivors of Traffic Accidents

According to Burmeister, 500,000 people are injured in traffic accidents in Germany every year, 100,000 of them with severe injuries. 10–30% of them develop a chronic post-traumatic stress disorder (PTSD) regardless of the severity of the physical injury (Burmeister, 2000, p. 202 f.). Action methods such as psychodrama involve the motor, sensory, and affective parts of the brain in treatment (Burmeister, 2000, pp. 200, 206). This also activates the trauma memory in the left brain. Burmeister primarily works in an individual setting. He adopts the therapeutic attitude of a doppelganger and a midwife when working with trauma victims. This promotes the self-determined, spontaneously creative action of the patient.

Burmeister divides his integrative therapeutic approach to PTSD into four phases: (1) Those affected react secondarily to their symptoms with feelings of shame, guilt, anxiety, and depression (Burmeister, 2000, p. 207). Therefore, the therapist informs the patient in detail about the clinical disease pattern of PTSD in the preparation phase. (2) He engages the protagonists in imagination processes. They should search for memories or scenes from myths, fairy tales, or fantasies, ‘which promote the ability to choose, to decide […] and to be effective again’ (Burmeister, 2000, p. 209). In doing this, the therapist helps them as a doppelganger. (3) He lets the protagonist psychodramatically set up psychologically stabilizing memories and fantasy scenes as a ‘safe place’ in the therapy room (Burmeister, 2000, p. 210 ff.). (4) The patient relives her trauma story through re-enactment. However, in doing so, she should modify it (Burmeister, 2000, p. 212 ff.). The patient must not stop at the moment of great shock. Instead, she should courageously end the story differently. In doing this, the therapist encourages her to use her own impulses as a starting point. (5) Unlike in the past, the whole event now takes place in the protective framework of the therapeutic relationship. Burmeister repeatedly uses various self-stabilization techniques, for example, the ‘safe place’, breathing exercises, or the teddy bears from childhood (Burmeister, 2000, p. 214). (6) The phase of reintegration into the social environment follows. For this purpose, Burmeister (2000, p. 215) uses, among other things, the technique of the ‘social network inventory’.