As Hardly Killed, as Easily Wounded: Posttraumatic Challenges to the Working Alliance*

Chris arrived in her new therapist's office with a list of her previous treaters. The list was long, the failures many. She complained that she had been misunderstood, pathologized, and exploited by therapists who lacked both skill and integrity. She needed a therapist, but felt little hope of finding one who knew how to understand and help her with her difficulties.

Developing and sustaining a treatment alliance with victims of early trauma can be notoriously difficult. Too many psychotherapies end in rupture or stalemate when therapist and patient become mired in struggles that express—and in turn create—conditions of fundamental unsafety in relationship.

This article examines why the therapeutic relationship is so difficult for such patients. It is proposed that chronic childhood mistreatment deprives the growing child of the relationship that creates potential space, and so of a context in which to develop both the self and the capacity to render experience symbolically. Posttraumatic impairments in the capacity for symbolic thinking lend an immediacy and concreteness to subjective experience that leaves little room for reflection or for other points of view. When negative transference emerges in the treatment relationship it is thus not amenable to interpretation (Hegeman, 1995). In order to contain this experience, therapist and patient must create connection in the face of material that is actively threatening to relationship. It is proposed that Winnicott's (1971) concept of potential space offers a way of