Trauma can be described as an overwhelming event that provokes terror, fear for your life or the life of others. However, when we talk about treating trauma, it is not the event but the overwhelming effects that remain as symptoms that require treatment. Most people are familiar with Post Traumatic Stress Syndrome (PTSD). During the 1960’s with the onslaught of symptoms seen in soldiers returning from Vietnam as well as the women’s movement bringing attention to the effects of rape and domestic violence, attention was being brought to the aftermath of living through trauma. PTSD however, was not added to the DSM until 1980. More recently the diagnosis of Complex PTSD was added to the ICD-11. This diagnosis is meant to include symptoms that result from prolonged or chronic exposure to trauma, but the DSM has yet to include this diagnosis. However, as most clinicians working with trauma will tell you, working with individuals who have experienced prolonged, chronic abuse or neglect often can produce severe symptoms that will need long term treatment.
Complex PTSD or Complex Trauma can have life- long consequences that can effect a person’s sense of self, others and the world. We know that an infant’s sense of self, others and the world is shaped through the earliest interactions with the environment. Early interactions with our caregivers, influences the infant's growing ability to regulate, to self soothe or to adapt protective strategies. These early interactions affect the developing brain and connections in our neuro-pathways that will become a template of our future emotional/affective responses to the environment. In this way, the brain comes to “expect” what has already happened, whether it expects to be welcomed, or expects the need for protection in relational interactions. An infant or toddler who is met with abuse or neglect internalizes the failure of his environment to support his needs, and internalizes a sense of shame, believing that, “I am bad, or defective, something is wrong with me.” Every child depends on their parents for their very survival, they have an innate need for closeness. When this is threatened the child instinctively blames themselves.
Further complicating the early childhood trauma, is the inability for the child to defend against abuse or neglect. Infants cannot fight, they can cry in protest but eventually will become numb or disassociated. They cannot flee. The only way they can respond is to freeze or disassociate. This dissociated trauma is stored in the infant’s or preverbal child’s unconscious, without words. It becomes an unconscious affective state that can be triggered without notice. This preverbal trauma cannot be accessed with words alone.
Another confounding factor is that often adults to not recognize the extent of the abuse or neglect that they lived through. Both because of preverbal memories not being accessible but also because they often have nothing to compare their experience to. For example, children growing up watching domestic violence may in fact feel terror, but over time accept that this is just the way my family is. Or children who are neglected, may not realize the extent of the neglect.
Often adults come into treatment, when they are experiencing problems in their relationships or with their work life, or experiencing depression, anxiety or a feeling of being stuck or numb, often having no idea of the underlying trauma. Some will even tell us how great their childhood was. What we know is that we don’t need to know what happened in the past. What happens in the present, in the room between therapist and client will give us a clear understanding of what happened in the past. Some of the things that we are looking for will be dissociation, a history of abusive relationships, the inability to maintain relationships, the inability to regulate one’s emotions, the inability to self soothe, a restricted range of emotions, and the use of unhealthy strategies such as over use of alcohol, drug abuse, eating disorders, excessive gambling or excessive use of sex or pornography to regulate stress and negative emotions.
In fact, as established in the early 1980’s by Judith Herman, trauma treatment should take a 3 phase approach. As Herman suggests,
- Establishing Safety
- Remembrance and Mourning
Stage one Establishing Safety should always be given all the time it's needed. For some clients this could take weeks or even months. The “Window of Tolerance” concept created by Pat Ogden and Dan Siegel refers to the space where we feel neither overly activated: anxious, panicked, raging, or under activated: depressed, numb, dissociated. We all have a range in which we feel at ease, but for trauma survivors that range is narrow and they can be easily bumped out of their window of tolerance. Helping someone to feel safe enough to do trauma work is no easy task. We are asking them to do something that they have every reason not to do: trust. Establishing trust must begin at the first session or even the first phone calls. Being able to be with the client, resonating with what they are feeling, while staying regulated is important in establishing the clients feeling of safety. Psycho-education can be done to help the client learn to notice cues in their body that tell them they are dysregulated, and to teach them skills that will help bring them back to the window of tolerance.
One of these skills to help return to the window of tolerance is called resourcing. This has to do with helping clients to identify resources they currently have that will help them to feel calm. These resources can be internal or external. Internal resources might include things that one values about themselves or strengths that they have identified. External resources might include using the senses like sight, sound, touch or taste, or tactile sensations. For example for some lighting a scented candle, petting their dog, or listening to a beautiful piece of music might be helpful. These things can be done in the imagination as well as in person. Whatever resources are used, it is important to make sure that the client has the ability to move back into the window of tolerance before moving into the next stage.
Moving back into the window of tolerance is also described as regulation. There are 2 strategies, self-regulation and co-regulation. Self regulation are those strategies such as described above those effecting our senses, scented candles, or beautiful imagery. The regulation that occurs in the relationship between therapist and client (similar to healthier mother/child relationship) is co-regulation. Part of the “work” in therapy is in establishing safety and trust through the therapeutic relationship.
Stage 2 Remembrance and Mourning is when the reprocessing of traumatic memories takes place. Modalities like EMDR therapy, Somatic Experiencing, Sensorimotor Psychotherapy or NARM are all excellent modalities that incorporate both mind and body. In the trauma field, we call this top down and bottom up work. For clients that have no memory of trauma it is essential to be able to work with the body and the states that have no words. Reprocessing can be done in small doses, but it is important for the therapist to stay attuned to the painful feelings that are arising and not to shy away because of their own discomfort in being with extremely painful feelings. Resourcing, grounding and helping clients to stay regulated are important to use in this stage as well.
Stage 3 Reconnection is about being with clients in their new ability to experience feelings and ways of being that they have not had access to in the past. For trauma survivors even positive feelings can be triggering. They sometimes have not had access to these feelings for so long that they might feel that something negative will be coming soon, or that they don’t deserve to experience happiness. They may even feel guilty when they are not feeling bad, or if they are now learning to take care of themselves. Being with clients as they begin to deepen their ability to connect with others, while they overcome the fear and as they open up to joy and aliveness is all a part of the healing process. Clients may begin to hope for things that they have previously thought were unavailable to them like love, joy, safety and a sense of belonging in the world.
As the window of tolerance grows, clients develop the capacity to feel deeper feelings on both sides, the pain of life, and the joy of life, but to feel them while remaining in a regulated state. Therapy is not about removing the pain of life, sometimes we feel depression and grief, but it also about opening us up to feeling the joy and the happiness alongside it. Being able to allow all feelings is an important part of healing and learning how to embrace them gives us a freedom in life.
If you would like to find out more about healing from complex trauma please contact us at Trauma and Beyond Center ® at www.traumaandbeyondcenter.com