Working with a guilt-inducing internal voice

I got a lovely email recently from a therapist reporting on a session:

 

I did a client session in November 2016 regarding old and new traumas with a 30-year-old woman who was sexually assaulted when she was 18. She had cancelled and rescheduled several times, but she finally found a time she could come without her two small children.

We were discussing the phobia process and when I asked if she had any questions, she was tearful, voice shaking, and she shared a strong disturbing thought, “You are going to take this from me.” She had a strong belief that she “should” feel the reactions to the memories of the assault (hypervigilance, somatic symptoms when memories arose, discomfort with physical contact with her partner).

We had planned to use the movie theater/rewind method to address the phobic response to her traumatic memories, but instead we addressed this negative internal voice that thought she “should” have this reaction. We shifted to the Troublesome Internal Voice Transformation method from the online PTSD training. She quickly identified the negative voice as being that of the boyfriend she had at the time (not the person who assaulted her), who shamed and manipulated her when he found out about the assault. She had a very profound experience when she realized this — her affect changed dramatically, she was quiet and smiling and relaxed, so there was no need to do the phobia process.

She said she hadn’t realized that the voice was “not me,” and when she had this realization, she felt free to stop listening to it. We’ve met twice since that session, most recently in early March, and the results have held. Below is the email I got from her the next morning after our session.

—Susan Malcolm LCSW, Portland Maine

 

“I literally cannot explain it. I am happy. I could not fall asleep last night because I am happy. I feel like I am that girl that was lost 12 years ago that was once so happy and liked herself. I am a little in shock from it still, but to have this box that was gross and oozing yesterday be beautiful and dressed up today is just amazing. All my anxiety that I have been having about everything is gone. I want to spend time with my kids, I want to talk to my husband about all the weird crazy things in my mind, and I don’t even care about talking about building a house anymore. (Yes, it’s still overwhelming, but I am not scared about it anymore.) It is literally unexplainable and amazing all at once. I cannot say thank you enough. I want this to be available for everyone. This is the craziest thing that everyone with PTSD should go through. E.V.E.R.Y.O.N.E.”

 

Comments by Steve Andreas

Susan’s lovely example is a reminder that when someone says they have a phobia, or PTSD, or anything else, those words may not accurately indicate the structure of what is troubling them. Many people use the words “trauma” and “PTSD” for a very wide range of different troubling experiences. If Susan had gone ahead with the phobia cure, either it wouldn’t have worked at all, or it might have worked with her memory of the assault itself. But it wouldn’t have resolved her crippling shame induced by the voice of her old boyfriend. It’s only too bad that she had to suffer needlessly for 12 years from something was so easily resolved in a single session. When Susan asked her if she recognized the voice, the realization that the troubling voice wasn’t hers probably only took a few seconds — a sweet example of what I call “Briefest Therapy.”