A woman who has experienced a traumatic event seeks counseling when she finds that symptoms related to the trauma affect her ability to enjoy life and function normally. She meets with her therapist once per week for 9 months, and she makes tremendous progress in therapy.

As she works hard and stays committed to the process of resolving her trauma, she feels very proud of herself and receives validating feedback from her therapist, who acknowledges her hard work and progress. She then notices that with the change of seasons, some of the symptoms she tried so hard to minimize or eliminate altogether come creeping back. She notices, as the time of year associated with her trauma approaches, her symptoms worsen still.

She becomes very frustrated. She fears she will experience the same degree of trauma she did immediately after the traumatic event. She wants to just give up. “What’s the point?” she asks herself and her therapist. “I have worked so hard and here I am, going right back to the trauma!”

Why Seasonal Change Can Reawaken Trauma

This case example illustrates a very common occurrence in trauma work. Trauma symptoms may resurface or worsen at certain times of year—it is almost as if the change in seasons is a catalyst that causes a person to feel as though they are regressing. It is easy at these times to dismiss the progress that has been made in therapy and focus, instead, on the reemerging symptoms. Rather than consider this a regression in therapy, I prefer to think of it as an expected occurrence in trauma work that should be normalized and discussed.

Several factors can be at play here. First, as the time of year when the traumatic event occurred comes around again, a very powerful reminder of the trauma often occurs. The brain is triggered and begins remembering. The body also remembers and symptoms reemerge.

Another consideration is that holidays can also trigger trauma memories and symptoms, especially if loss has occurred. The loss of a loved one is one of the most common and difficult traumatic events humans can experience. Even if the loss did not occur around the holidays, holiday times often serve as reminders of loved ones who are deeply missed.

Furthermore, according to the American Psychiatric Association, 80% of people who meet criteria for a diagnosis of posttraumatic stress disorder (PTSD) also meet criteria for other mental health diagnoses. In my experience, one does not have to have an actual diagnosis of PTSD to become more susceptible to other troubling mental health symptoms after a traumatic event. Just experiencing a traumatic event can make someone more likely to experience symptoms related to anxiety, depression, and other challenges.

Certain times of the year can make symptoms worse. For example, with colder weather and less daylight during the winter months, a trauma survivor who also experiences symptoms associated with seasonal affective disorder (SAD) may encounter a worsening of both SAD and trauma symptoms. Similarly, someone prone to anxiety may find symptoms flare up during the holidays, when more cars are out on the road, malls and stores are more crowded, and financial and social pressures are mounting.

Unfortunately, many people are ashamed to talk about reoccurring or worsening symptoms, and this can cause symptoms to escalate even more, impacting well-being and functioning.

Addressing Reoccurring Trauma in Therapy

Unfortunately, many people are ashamed to talk about reoccurring or worsening symptoms, and this can cause symptoms to escalate even more, impacting well-being and functioning. Beliefs may surface that all the time and hard work one has given in moving forward from a traumatic experience has been wasted. Feelings of frustration and an urge to give up on therapy are very common during these times, as illustrated in the case example.

In addition, a fear of disappointing one’s therapist may come up, preventing some people from openly discussing new or reoccurring symptoms. Making progress in therapy is validating and rewarding, as the case example demonstrated. Returning to therapy when symptoms reoccur can bring up feelings of shame or guilt, causing one to feel as though they will somehow disappoint the therapist or that the reoccurring symptoms will suggest to the therapist they are not working hard enough.

Reemerging Trauma as an Opportunity for Healing

I find this point in trauma work is sometimes the most critical, when clients have a wonderful opportunity to make the most progress toward resolving their trauma for good. This is the time to talk to your therapist to let them know exactly what you are experiencing and how it is making you feel. A good trauma therapist will validate and normalize what you are going through and help you to confront the fear of reoccurring symptoms so that when other triggers come up, it is not so daunting to confront them. This is an opportunity to practice skills with your therapist that will reinforce that you are strong and capable of handling whatever may come up.

Going back to our case example: The therapist validated and normalized what the woman was feeling and experiencing. She reassured the woman that what she felt was very common in trauma work and presented it as an opportunity. The woman stuck with therapy, continuing to talk about her urges to give up on therapy and her feelings of disappointment as they came up. She continued working hard and trusting the therapeutic process.

She was able to overcome her reemerging symptoms. The time of year that served as a trigger passed, and she found that when she thought of that time of year rolling around again, she was not as distressed as she expected. She felt better and more confident as she moved forward. Eventually, she did not need to see her therapist anymore, although she always knew she could return if she felt the need. And when the next trigger appeared, she handled it beautifully, which just reinforced her strength and the belief that she could continue to move forward.

Reference:

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.

My work with people often drives me to explore themes that are currently showing up in my counseling practice. If you are a counselor, you know what I mean. You may have many clients or therapist consultees presenting with the same needs, perhaps some who are saying similar things of late. That’s not to say that these issues are the “same,” for they are not. Nevertheless, there are topics that may repeat themselves. I pay attention to these because I believe that there is much to explore and learn by being aware of patterns.

A pattern I have seen of late is related to eye movement desensitization and reprocessing (EMDR) work, specifically about the process of being “ready” to do EMDR. I have had a lot of therapists inquiring about their clients’ readiness to do EMDR. Keep in mind that if you are doing EMDR, you are always doing EMDR; it just depends on the phase you are in. If you are one of my EMDR clients or therapist consultees, you know how much I emphasize this as key to understanding the EMDR therapy model. Keep this in mind: EMDR is a process, a model, and not a technique.

EMDR’s preparation phase is phase two of the eight phases of EMDR. EMDR therapists look for people to have a minimum of two state-change skills as part of this phase. In phase two we are making sure that the client has the ability to not only tolerate emotion, but also to shift into a relaxed state, a para-sympathetic response. In other words, can the person bring up a disturbing event, be “in it,” but then also utilize a relaxation skill or calming technique to then change states if needed?

Keep in mind that the concept of changing states may be something that sounds easy, but for many it is not. Some folks seeking to utilize EMDR therapy as part of their trauma recovery may need more extensive preparation-phase support. This is especially true in the case of those struggling with dissociation and addictions.

In its simplest form, a state change means being able to utilize a relaxation skill to settle down one’s system. State-change skills can help the EMDR client to become calmer and more settled while still maintaining “dual attention”—i.e., being present while bringing up traumatic disturbance(s). In contrast, and though it may appear like it, the ability to utilize state-change skills does not mean changing states via dissociation. Certainly, one’s ability to dissociate may appear similar to a state-change skill, and is a survival skill, but dissociation keeps us “away from” traumatic material and from integrating the somatic, visual, emotional, and cognitive aspects of it to then heal.

For example, dissociation takes one away from the present moment because the past feels as if it is happening now and it feels safer to leave the present. But to be able to heal and integrate the traumatic material requires that state of being present. We just have to learn the dance between feeling the disturbing material and being able to shift into a contrasting, calmer state.

In exploring the concept of EMDR and state-change skills, addictions can also be explored as an attempt to chemically or behaviorally illicit a state change. I often explain to people that substance abuse is often driven by an ill-fated attempt to chemically dissociate. One can easily become entrenched in the vicious cycle of using addictive substances and behaviors to shift “out” of traumatic material in order to feel something, anything, and everything different from the pain of a traumatic history. And, for many people, addictions have become a way to change states, to feel away from and out of traumatic material.

The bottom line is that to heal, trauma histories beg to be accessed, stimulated, and reprocessed. The challenge can be in our making sure that EMDR clients are fully supported in having the state-change skills in place to be able to come back, to ground, and to stay present first. Therefore, creating and implementing these state-change skills can be the key to supporting EMDR clients in their recovery and throughout EMDR’s eight phases.

Those who have endured trauma experience unique challenges in coping with life after the fact. It may feel as though no one understands the anxiety, depression, nightmares, flashbacks, and other issues characteristic of posttraumatic stress.

Because of this, people who have experienced trauma tend to avoid intimacy and closeness in relationships. While it may be difficult for a partner, family member, or friend to offer the necessary support, there are professionals who are very familiar with what it takes to heal and recover from a traumatic incident.

Clinical psychologist Robert T. Muller, PhD, wrote a book on the subject: Trauma and the Avoidant Client: Attachment-Based Strategies for Healing, which was published in 2010. As part of our continuing education web conference series, GoodTherapy.org was fortunate enough to have Dr. Muller present on “Engaging the Traumatized Client Who Avoids Closeness and Vulnerability” in April of 2011.

Recently, Dr. Muller, who is also an associate professor at York University in Toronto, Canada, shared some of his insights with us in a written interview on roughly the same topic. Specifically, he reveals the common traits associated with those who have developed avoidance-based coping strategies in response to trauma, and he discusses how to help these individuals in therapy.

GoodTherapy.org (GT): What do you think is the biggest obstacle in overcoming trauma?

Robert T. Muller (RTM): The biggest obstacle is fear. Fear of getting hurt … yet again. Fear that people who seem trustworthy aren’t. It requires great fortitude to open up and take interpersonal risks when you were hurt by the people you trusted most.

GT: Why do people with a history of trauma often have trouble in interpersonal relationships?

RTM: A client of mine once told me, “You live what you know.” When what you know is betrayal, that’s what you live.

GT: What does attachment have to do with trauma?

RTM: Humans naturally seek closeness. Trauma takes away what is most natural, making simple interpersonal contact scary and complicated.

GT: Are trauma survivors more resistant to therapy than other people who seek counseling?

RTM: No, they’re not more resistant. And they can be rewarding to work with, even inspiring. But it’s not easy. For therapists, the trick is being open to difficult painful truths: The world is often unjust, [and] good people suffer. We can’t rescue our clients from their painful histories, but we can help them gain understanding and empathy for themselves, rather than judgment and self-reproach.

GT: What kinds of therapeutic strategies work best with trauma survivors?

RTM: Relationship, relationship, relationship. With survivors of interpersonal trauma, change happens through the here-and-now relationship between client and therapist. As a therapeutic alliance develops, as the client starts to feel a connection to the clinician, this feels scary, and the person struggles as they do in all relationships: They don’t know how to trust. They may push the therapist away (because that’s easier than worrying they’ll be abandoned); they may even criticize the clinician or become angry at times. How the therapist weathers these moments in the relationship makes all the difference. If the clinician becomes defensive or critical, it’s game over. But if the therapist sees this as an opportunity, an important moment in their relationship to help the client work through the conflict between them, that’s where change really happens. The person truly learns how the world of relationships can be nonexploitative and rewarding.

GT: How can therapists engage avoidant trauma survivors in therapy?

RTM: Even clients who avoid closeness and painful feelings are in the therapist’s office for a reason. Find that reason. What’s in it for them to change? Working with them can be hard, because they’re masters at pushing people away. The trick is seeing their distancing maneuvers for what they are: fear of closeness.

GT: What do you hope therapists will take away from your new book, Trauma and the Avoidant Client: Attachment-Based Strategies for Healing?

RTM: Up to now, avoidant trauma survivors have been ignored by the field of mental health; that’s a missed opportunity. As a way of avoiding closeness, they drink, become workaholics, get addicted, overdo food or exercise, and so on. But those strategies don’t work, at least not in the long run. Ultimately, they need to experience the emotions that go along with closeness; to feel loss, sadness, pain, and vulnerability without becoming terrified of losing control or falling apart. The best tool I know is the therapeutic relationship. My book focuses on how to help clients like these by skillfully using the therapeutic relationship as a vehicle for change. What they fear is closeness, but underlying that fear is a painful longing, a yearning to feel loved. And at the end of the day, therapy is about learning how to allow yourself that gift.

We all have many wounds. Broken hearts, shattered dreams, abuse, and trauma all leave battle scars that may not be outwardly apparent to others, but can cause a lifetime or even generations of experiencing the same issues, as patterns are often repeated and handed down as part of the family legacy.

The pain sustained throughout the years frequently leads us to develop defensive shields that serve to protect our vulnerable hearts from being wounded once again. And yet, this outer armor ends up not only closing us off from others, but also ultimately from the beauty and wonder of our own souls.

As a psychotherapist working from a depth perspective, I have been fascinated and privileged to have been able to witness the soul at work every day in my interactions with clients, as well as out in the world. The soul always strives to attain a state of wholeness or unity and seeks to reestablish harmony when an imbalance exists.

For example, I have frequently noticed that individuals with deep inner wounds often spend a lot of time engaged in outer pursuits in order to avoid looking within and facing the discomfort that they feel, yet at the same time they often experience a deep yearning for something more meaningful in their lives. If the gap between their inner and outer state becomes too painful to bear, they may finally feel compelled to explore their inner world through some type of creative endeavor, spiritual practice, or by entering into an empathic therapeutic relationship. This type of inner work can lead to an inner transformation that creates a more balanced perspective.

One of our fundamental needs as human beings is to be deeply heard and understood. When we experience pain in silence, we tend to feel cut off and separated from others and unable to enter into satisfying relationships. Unfortunately, as we grow up, we are taught that certain aspects of ourselves are unacceptable and unlovable, which in turn leads us to feel different from others.

We therefore start to reject those traits and identify only with the characteristics that are deemed pleasing to others in order to try to fit in. But deep down, we are aware of this inner conflict that is going on between our outer persona and our inner authentic being, which can lead us to feel unworthy of love and disconnected from ourselves and from others. In order to heal, we often require the presence of an empathic other to help us to examine more closely the inner dynamic that has been occurring.

Soul work involves shining a light inward in order to begin to integrate more and more aspects of our being that we have learned to repress. Individuals who have gone through trauma or abuse especially can end up with deep scars that lead to feelings of unworthiness, low self-esteem, and fear of true intimacy. They frequently learn to hide their true nature behind a false self as an adaptive measure designed to protect them from the trauma or abuse that they have suffered.

In so doing, they inhibit all of the characteristics that they believed to be unlovable or unwanted, but that actually make up a vital part of their essence. By turning their gaze inward, however, and exploring the aspects that they had originally rejected—often because they were deemed unacceptable or shameful—they can reconnect with their ability to love on a deep level and become more compassionate and understanding of others, as well as of themselves.

The Apaches have a legend that exemplifies this inner soul work. They believe that our spirits are born with us in the form of raw diamonds and that our goal in life is to obtain as many facets or cuts on our spiritual diamonds as possible. Each facet polishes the diamond and makes it shine a little more.

A new cut is formed every time we are faced with a problem or difficulty in our life and we use the opportunity to try to learn something new about ourselves. All of the struggles and suffering that we are faced with therefore become occasions for us to grow and fulfill our purpose for living. At death, the Apaches believe that our diamond spirit is returned to the Eye of God, to shine within the heavens for all of eternity. Each facet becomes another sparkle in the Eye of God.

In the same manner, I believe that turning our attention inward and doing our own soul work is our true purpose in life, which can lead us to experience a greater sense of wholeness and unity. By starting to look at the deeper patterns at work in the soul and how these are played out in our lives and in the world, we can begin to see our interconnectedness with all beings and things.

Each individual soul has a particular path to follow that intertwines with all of the others around it. By working to become more conscious of our own particular role and purpose in the world and how we relate to others, we can begin to heal from our sense of isolation as separate beings and come to feel that we are all truly connected on a deep soul level.

Many people believe that when experiences are too painful or difficult to face, they end up tucked into the unseen corners of the unconscious in the form of repressed memories. The presence of hidden truths in the psyche may then manifest in myriad ways in waking life: panic attacks, nightmares, anxiety, depression, sexual dysfunction, and issues with self-esteem, to name a few.

Sexual trauma, in particular, is viewed by a number of therapists as being especially susceptible to repression (Loftus, 1993). The memories may remain locked away for years before surfacing, which typically occurs in a therapeutic setting.

Several people, mainly women, who recollect memories of abuse 10, 20, 30, or more years after the abuse occurred have sued the perpetrators in court for damages to physical and psychological well-being. Many have won.

However, over the past few decades, the notion of repressed memories has sparked a great deal of controversy in the mental health field. This became especially heated during what became known as the “memory wars” of the 1990s.

Clinical psychologists and therapists who have witnessed adult clients remembering repressed experiences of childhood abuse argue that the memories are real, vivid, detailed, and reliable. Researchers tend to be more hesitant to accept the concept of repression as fact due to the lack of scientific evidence in support of it (Association for Psychological Science, 2013).

Findings reported recently in Psychological Science suggest that this controversy remains just as prevalent today, and that skepticism has actually increased with time. One of the researchers, Lawrence Patihis of the University of California, Irvine, said in a press release issued by the Association for Psychological Science (2013), “Whether repressed memories are accurate or not, and whether they should be pursued by therapists, or not, is probably the single most practically important topic in clinical psychology since the days of Freud and the hypnotists who came before him.”

The study conducted by Patihis and colleagues involved an online survey of practicing clinicians, psychotherapists, research psychologists, and alternative therapists. Their responses revealed that though skepticism regarding repressed memories has increased in the past 20 years for “mainstream psychotherapists and clinical psychologists,” approximately 60 to 80% of the clinicians, psychoanalysts, and therapists who responded to the survey believe that memories of trauma are often repressed and can be retrieved in therapy.

They also gathered data that shows the widespread acceptance of repressed memories as real among the general public. On the other hand, less than 30% of research psychologists believe in the validity of repressed memories.

Repressed-Memory Testimony Fuels Controversy

One of the primary concerns of skeptics is that “repressed-memory testimony” may be used in court to indict someone. Being able to testify against long-ago abusers has been known to aide in the healing and recovery of many who endured childhood sexual or physical abuse. However, there have been instances where an adult child accuses parents of abuse years after the fact and the parents vehemently deny the accusation; this inevitably tears apart familial relationships and leaves the accused feeling victimized (Loftus, 1993).

Repressed-memory testimony has also been used to solve unsolved cases of murder, as in the 1990 case of Eileen Franklin, who experienced sudden and vivid repressed memory recall as a 29-year-old mother that revealed a dark secret: When she was 8 years old, her father had raped and murdered her best friend; Eileen had been witness to the crime, and her father had threatened to kill her if she ever told anyone. Her then 51-year-old father George was tried in court and convicted largely based on the evidence provided via Eileen’s memories, although corroborating evidence gathered at the time of the crime was also taken into consideration.

The disturbing number of cases related to repressed experiences of childhood sexual abuse by Catholic priests and other private group leaders has also stirred much dialogue over whether memories that surface years after an alleged incident occurred should be used as evidence in legal cases. As recently as October 2013, Governor Jerry Brown of California vetoed legislation that would have allowed more victims of childhood sexual abuse to take action against the Catholic Church, Boy Scouts, and other private organizations (Miller).

For those who experienced the abuse, being able to seek justice for the wrongs committed against them is essential to their ability to move on and recover. Many of them experience years of psychological torment prior to remembering in full the abuse that took place, and their supporters believe lawsuits should be an option regardless of how long it takes for those memories to appear (Miller, 2013).

Considering that the truth of a resurfaced memory is often nearly impossible to prove with scientific evidence, this may be a situation where researchers should defer to the practicing psychologists and therapists who have witnessed countless cases of repressed recall in action, as well as the people who attest to their validity firsthand and experience intuitive healing as a result.

References:

1. Association for Psychological Science. (2013, December 13). Scientists and practitioners don’t see eye to eye on repressed memory. [Press Release]. Retrieved from http://www.psychologicalscience.org/index.php/news/releases/scientists-and-practitioners-dont-see-eye-to-eye-on-repressed-memory.html
2. Miller, J. (2013, October 13). SEX ABUSE: Governor vetoes bill to allow more victims. The Press-Enterprise. Retrieved from http://www.pe.com/local-news/politics/jim-miller-headlines/20131013-sex-abuse-governor-vetoes-bill-to-allow-more-victims.ece
3. Loftus, E. (1993). The reality of repressed memories. American Psychologist, 48, 518-537. Retrieved from http://faculty.washington.edu/eloftus/Articles/lof93.htm

Thank you for writing. I am so sorry this happened to you. It frankly makes my blood boil. This breach and exploitation is exactly what therapists are never supposed to do. To me, it’s akin to incest. I’m glad you’re reaching out about it. Despite whatever conflicted feelings you might be having, please know that this was not your fault in any way. Maintaining that professional wall and keeping the boundary between healer and client is solely the responsibility of the therapist. Psychological safety and doing no harm is our top priority. It’s heartbreaking that your therapist so violated the sanctity of the relationship.

Of course, from a psychological viewpoint, this kind of gross violation of boundaries and trust will bring up all kinds of conflicted and traumatic feelings for the client. (This is one of many reasons that such a breach indicates the therapist has lost her way in the profession.) What’s especially tragic is that this experience may have parallel emotional resonance for those who were abused or neglected as children. One of the most common misperceptions by victims of such abuse is that they think, somehow, in a desperate effort to make sense of a painfully chaotic phenomenon, that they “caused” or “brought on” the abuse. Therapy is set up so that it really is all about the client; when this kind of abuse transpires, how can the client help but think (among other things) that the violation is somehow “about me”? Trust me: This is about a malpracticing therapist.

The feelings you’re having are quite understandable; however—and I hate to say this—they most likely won’t just go away on their own. You allude to this in your letter in that, five years hence, the pain lingers. In a way, it means you have a communicative psyche that needs some sustained, loving attention; you deserve the care and guidance of a competent therapist to help you heal. The fact other therapists wanted you to press charges may be a sign of how seriously we take our oath as healers—it’s enraging when we hear of violations of that oath. However, you are not obligated to do anything that feels too scary or overwhelming. You may want to press charges at some point, you may not. That doesn’t seem to be what you’re needing right now, and such a decision can come later, if ever. It’s not your job to “police” anyone. We don’t want to create a situation wherein we “blame the victim.”

The first step is a healing process wherein you can reintegrate and reconnect with whatever had to be dissociated or sacrificed to live with the hurt of this abuse. Other decisions will likely follow of their own accord.

I’m curious as to your statement that “most people don’t believe a woman can abuse another woman.” Since that falls outside the range of my own experience, I would want to know more about that, i.e. who “most people” are. Most people in your circle of family and friends? Potential authorities who would evaluate this case? Has your mistreatment at the hands of others ever been doubted?

You are alluding to what I call the double whammy of trauma—first there is the painful abuse itself, and then (and this is often what causes the real hurt and disruption) the denial or minimization of the abuse. It’s possible that we can heal from hurtful events if those who participated acknowledge both the event and their participation, followed by their amending such behaviors. With the repetition of abuse and denial, and no commitment by the abusers to cease, we begin to wonder if we are in fact “exaggerating” or even “crazy.” A painful split emerges between mind and body, as we doubt our own perceptions, memories, and physical reality. This takes a lot of time to heal, to reconnect with and trust our own emotional experience and intuition, but repair is possible. Your perspective on these events may shift once the fractures begin to heal.

You may need to tell your therapist—and I’m hoping you have one you trust, or want to find one—that you’re not interested in pursuing any reporting or recriminatory actions just now. It sounds like you need now to put yourself first, make sense of what happened, and engage in a healing process with someone who will cherish the trust you give to him or her. It is a privilege for us to be trusted, and it’s something we have to earn. Don’t feel in any hurry—in fact, I’d encourage you to go at a pace that feels right to you.

I’m sorry this happened, but so glad you wrote in. I hope this answer helped in some small way. Please don’t give up on finding the right person, in spite of this awful breach. Warmest good wishes to you.

Kind regards,
Darren

Following a traumatic event, several symptoms may arise in a person. Posttraumatic stress manifests in a variety of ways: reexperiencing the trauma via nightmares and flashbacks, avoidance of people and places that trigger memories of the event, elevated states of anxiety and arousal, and being in near-constant fight-or-flight mode, to name a few. These symptoms may last days, weeks, months, or years following traumatic experiences such as wartime combat, childhood abuse, rape, kidnapping, natural disaster, traumatic injury, or sudden death of a loved one.

Processing the emotions tied to these memories is often unsettling, and recovering from traumatic experiences typically requires a great deal of support and guidance. The good news is that there are several websites and organizations devoted to helping those who have been subject to trauma. Many are geared toward military veterans; however, plenty of sites focus on recovery for those who were victims of other forms of trauma, such as abuse or assault, whether as children or adults.

[fat_widget_trauma_ptsd_right]

We’ve compiled a list of the 10 best online resources for PTSD and trauma—GoodTherapy.org excluded—in 2013. As with our previous top 10 lists, our selections are based on quality and depth of content, presentation, and functionality.

• National Center for PTSD: The U.S. Department of Veterans Affairs hosts this site dedicated to research and education on trauma and PTSD in the lives of veterans. There is an informational section for veterans and their loved ones, as well as for professionals who are researching and providing care for those experiencing PTSD.
• Make the Connection: This site focuses specifically on offering “shared experiences and support” for veterans. The emphasis is on the power of support in the recovery process; veterans can locate local resources and access a wide range of information on dealing with PTSD as well as transitioning from service, the death of family or friends, and alcohol or drug problems. The video gallery features several personal stories of military veterans who have found hope and recovery in spite of flashbacks and other experiences. Online self-assessment screenings are also available to determine if a veteran has PTSD, depression, or a substance-abuse issue.
• Posttraumatic Stress Disorder Alliance: This network of professional and advocacy organizations has come together to provide an array of educational resources for those experiencing PTSD and their friends and family. In addition to combat veterans, the site is geared toward those who have experienced rape, physical assault, other forms of sexual assault, domestic or intimate partner violence, serious injury or accident, shooting or stabbing, sudden death of a loved one, childhood illness, witnessing a serious crime, and natural disaster. The PTSD Alliance also offers two free, downloadable booklets in their “resource center” to guide people through recovery.
• Gift From Within: This international nonprofit for survivors of trauma and victimization is in its 20th year of service. The site is rich with resources, information, and useful tools for those recovering from trauma of many kinds. In the “trauma support” section, tips from survivors for therapists, guided meditations, and stories from “support pals” can be accessed. In the bookstore, visitors can sift through a number of titles organized by topics, such as children and teens; healing and recovery from illness; healing and recovery for survivors and supporters; PTSD treatment, trauma, and violence; sexual abuse—male and female; and sexual assault, rape, and domestic violence.  There are also DVDs on PTSD available for purchase.
• Real Warriors: Another site devoted to combat veterans and their loved ones, Real Warriors is an engaging, content-rich resource for help with the “invisible wounds” of war. The general message is that no one goes into combat and comes home unchanged, and that cultivating resilience and “real strength” is essential to recovery. Videos and podcasts are available for viewing and download, and veterans are encouraged to reach out and get the help they need. Several veterans share their personal stories of PTSD on the site, and others are encouraged to do the same. There is also a military crisis line and live chat number for those who need immediate assistance.
• My PTSD: This site is primarily a network of forums for those who are experiencing PTSD. Specific forums are designated for combat, domestic violence, sexual abuse, and traumatic stress, as well as a general PTSD discussion thread. There are also smaller threads for topics such as book clubs, events, studies and research, and recommending trauma physicians. In the “articles” section of the site, several insightful pieces are available on a variety of helpful topics such as finding negative core beliefs, recovery, effective treatments for PTSD, and treating the trauma of rape with cognitive behavioral therapy, among others.
• Trauma Survivors Network: In partnership with hospitals across the United States, the American Trauma Society created this community-oriented network of people and their families recovering from trauma. Through the Trauma Survivors Network, people can access local trauma center information, peer support groups, peer visitation opportunities, a parent and family handbook, survivor stories, a community forum, and more. TSN’s “NextSteps” program helps survivors to become autonomous self-managers while recovering from trauma. There is also a “family class” for those who are in caregiver and support roles for those who are experiencing PTSD.
• Sidran Institute: The Sidran Institute is a nonprofit organization devoted to helping people understand and recover from PTSD, dissociation, and co-occurring issues such as substance abuse, self-harm, and suicidal ideation. The site offers educational articles, resources, and information for adults, adolescents, and children who have survived trauma, as well as for schools, community support groups, and mental health and victims services professionals. Trainings are also available through the site for those who wish to deepen their knowledge of PTSD and other trauma-related issues.
• PTSD Association: Along with being greeted by a PTSD self-assessment test, visitors to this site will find a large body of useful information pertaining to PTSD. Founded by Ute Lawrence-Fisher, who survived the “most horrific car pile-up in Canadian history” in 1999, the PTSD Association aims to help those who are recovering from trauma to reclaim their lives. Clinical information, personal stories, coping strategies, and related links are among the resources available.
• National Child Traumatic Stress Network: With informational sections for parents and caregivers, medical professionals, military children and their families, and educators, the National Child Traumatic Stress Network (NCTSN) covers all bases of child traumatic stress. Established by the U.S. Congress in 2000, the NCTSN offers guidance, tools, and links for coping with and recovering from neglect, natural disasters, sexual or physical abuse, terrorism, grief, refugee and war-zone trauma, traumatic illness, early childhood trauma, and school, community, or domestic violence. Numbers for various child and adolescent crisis lines are also provided.

Have a website you would like to see in our Top 10? Recommend it here.

Major depression (MDD) is known to affect numerous cognitive and behavioral domains. People with MDD often have pessimistic attitudes about future events and guilt over past events. They tend to isolate and withdraw, and choose to engage in activities that provide immediate reward over those that promise future enjoyment. This leads to impulsive and even risky behavior, like overeating and substance misuse.

Posttraumatic stress is an anxiety condition that has some similarities to MDD, but is unique in that risk/reward choices tend to be quite different. Understanding how people with MDD, PTSD, and MDD+PTSD value risks over rewards is an important area of clinical research and can provide insight into the behavioral and cognitive processes that take place in people with these mental health problems.

To get a closer look at the differences in decision making that occurs in these conditions, Jan B. Engelmann of the Department of Economics at the University of Zurich in Switzerland recently conducted risk/reward decision making experiments on 20 individuals. All had either MDD or MDD+PTSD. Engelmann compared their choices to those of 16 control (HC) participants.

The results showed that both MDD groups discounted long term rewards compared to controls. For gains, both MDD groups selected immediate versus long-term gains more than controls. However, when Engelmann looked at the subgroups of MDD participants, the findings revealed significant differences. The MDD only group demonstrated a preference for taking larger losses in the long term if it meant decreasing immediate losses. This was in contrast to the HC and MDD+PTSD groups, who chose smaller immediate losses over larger losses in the future.

Engelmann believes this difference in the MDD and MDD+PTSD group is due to anxiety. The PTSD group may be more willing to accept minimal losses today if it means avoiding larger losses later. This avoidant behavior is a symptom of anxiety and in the case of risk/reward may actually benefit individuals with respect to decision making.

For people with MDD+PTSD, although anxiety may decrease antidepressant efficacy, this negative consequence may be offset by the positive effect anxious symptoms appear to have on risk/reward processing. “Together,” added Engelmann, “These results inform future research investigating the underlying affective and cognitive processes, as well as related neural mechanisms, of the observed choice distortions in patients with MDD.”

Reference:
Engelmann, J.B., Maciuba, B., Vaughan, C., Paulus, M.P., Dunlop, B.W. (2013). Posttraumatic stress disorder increases sensitivity to long term losses among patients with major depressive disorder. PLoS ONE 8(10): e78292. doi:10.1371/journal.pone.0078292

Trauma brings with it flashbacks of memory and strong emotions, which are often uncomfortable and difficult to cope with. Typically these symptoms are followed by the fight-or-flight response. This is natural, as instinct tells us to do everything we can to avoid pain and discomfort. Unfortunately, avoiding trauma symptoms can be detrimental instead of helpful. Resisting and avoiding trauma symptoms often brings on more intense emotions as well as increased frustration, anger, and panic.

I often use this analogy to explain why this happens: Imagine you are out in the ocean, far from shore. Giant waves are coming, very intimidating and scary. The first instinct is to fight, to swim as hard as you can back to shore. However, unless you are a physical anomaly, you only end up exhausting yourself and don’t get closer to your goal of safety. When exhausted, you are at higher risk of drowning. Thus, survival experts advise that the best thing you can do in this type of situation is to allow your body to relax to conserve energy, floating instead of fighting. This gives you a better chance of getting through the ordeal and allows time to calm yourself so you can think clearly about what to do to in order to survive.

I advise clients to do the same thing when they are experiencing trauma symptoms. On many occasions, I have seen shock and confusion on their faces when I tell them to stop fighting their symptoms and to just go with them—not making them worse, but also not fighting or avoiding. It sounds absurd, I know, to advise against fighting panic, awful memories, intense emotion, and flashbacks. After all, don’t we want relief from those symptoms? Of course we do. It is natural to want to be without pain. I ask people to take a risk and try just riding the waves of their symptoms, experiencing and observing them without feeding into them and making them worse—all the while not trying to make them better, either.

[fat_widget_trauma_ptsd_right]

When we try to make our symptoms better by fighting or avoiding, we are often fighting a losing battle. The body and brain are amazing. They know what they need to do to work through trauma, and we often get in the way of that process because it is uncomfortable and sometimes downright painful. Healing often involves pain. Think about a time you had an injury of some sort (a broken bone, a sunburn, a cut, or any other physical ailment). Think about the healing process and how it wasn’t always comfortable. Often there are uncomfortable or painful sensations that come as a result of the body trying to heal itself. The same is true when we have experienced a traumatic event. Our brains need the chance to process what has happened. When we fight or avoid the discomfort, not only do the symptoms last longer and become more intense, but we become frustrated because we were not successful in getting rid of the symptoms as soon as we wanted to.The good news is this: I have seen the awe on the faces of people when they allow themselves to experience and observe their symptoms, and find that it does indeed work to decrease the intensity and duration of their emotions, flashbacks, and panic. They find that their symptoms have far less power over them and they are able to increase their ability to function in their lives. This is what riding the waves is all about. The goal is to decrease the suffering in a way that is conducive to healing.

To learn to do this, I would advise that someone experiencing trauma reach out for professional help for a few reasons. First, this process can be scary, and a professional can give you the support and monitoring necessary while you are developing this technique. Also, additional coping skills are helpful and necessary when one is learning to ride the waves of their symptoms. Lastly, a professional can help you to develop a comprehensive treatment plan for trauma that will be tailored to your individual needs so you can get the best outcome possible.

No one is immune to trauma, and it is not something that we can always prevent. Life is traumatic. We cannot really plan for disasters, car accidents, loss, and other traumatic events that tend to take place in our lives. One study found that among the population in the Netherlands, 80.7% of participants had experienced a traumatic event (de Vries and Olff, 2009). The study goes on to state that this rate is comparable to the rate of traumatic events experienced in the in the United States. Human beings, no matter how strong, become vulnerable when they experience high levels of stress. Experiencing a traumatic event does not necessarily mean a person will develop posttraumatic stress, but it makes a person more likely to.

People experience trauma to varying degrees. Regardless of the degree of trauma experienced, the journey through trauma recovery can be an emotionally intense process which can, at times, seem daunting. I have noticed four similarities among people who are working through trauma that I felt would be beneficial to write about, as I see these traits so consistently.

1. Feeling alone and vulnerable: I have had people tell me that experiencing a traumatic event leaves them feeling alone and vulnerable. This is very normal. As I mentioned above, no one is immune to trauma, and even people with a strong sense of self and high self-confidence can find themselves feeling as though they are wandering through the dark alone, with no idea where they are going. I cannot stress enough the importance of having a good support network as one works through trauma. It can make all the difference in the world, especially if one is willing to talk about what they are going through and accept support from others. Wandering around in the dark is terrifying, and we all need other people sometimes to help us get through the dark so we can reach the light.
2. [fat_widget_trauma_ptsd_right]Experiencing intense emotion: A common experience of someone who has experienced a traumatic event is intense emotion, sometimes at unexpected times and without any known trigger. I have had many people mention that sometimes they will cry for “no reason” or suddenly become angry or afraid, which confuses and sometimes scares them. It is understandable that this would be confusing and scary, but it is normal and just part of the process of working through trauma. Intense emotions and trauma go hand-in-hand, and part of healing is allowing oneself to experience the emotions that come up. I believe that our brains and bodies are perfectly able to work through trauma, but it takes some pain to get to the healing. Trauma is like having an injury—such as a broken bone. In order to heal properly, that bone may have to be reset, which can be very painful. Through the healing process, the bone might continue to cause the person pain, but as the healing progresses, the bone should hurt less as long as it has the proper support and care. Emotions are usually where the pain is for people with trauma. Being willing to experience emotion, and learning skills to appropriately cope, can make those emotions much more bearable and easier to work through. Like a physical injury, when trauma is receiving the proper treatment and support, it will begin to hurt less.
3. Having disturbing thoughts and/or flashbacks of the trauma: I don’t think I have seen one traumatized person who did not have disturbing thoughts, flashbacks, or both about the traumatic event. This is what trauma does: it tends to stick in one’s brain and pop up, uninvited, whenever it wants. This is nothing to be ashamed of, and this is where support can be helpful in the form of trusted loved ones, support groups, and trauma professionals. There are skills available which tend to be quite effective in addressing these thoughts and flashbacks.
4. Feeling as though it will never get better: Hopelessness is one of the (unfortunately) common side effects of trauma. The good news is that there are excellent therapeutic interventions that are proven effective in treating trauma. I have treated people who experienced years of severe trauma who have found relief and have been able to have a normal, healthy life. There are several options for treatment, and finding a good therapist who is skilled in treating trauma can make all the difference. It does not matter how long ago the trauma happened or how severe it is. There is always hope for recovery!

Of course, this list is not exclusive.

It is so important that people dealing with trauma know that they are not alone in what they are experiencing and to know there is hope for recovery.

Reference:

De Vries, G.J., and Olff, M. (2009). The lifetime prevelance of traumatic events and posttraumatic stress disorder in the Netherlands. J Trauma Stress, 22 (4), pp. 259-267.

My mom has worked as a nurse for over 30 years. I remember she would sometimes come home from work and talk about how she had had a doctor or nurse as a patient that day. She would always say how health-care professionals were always the worst patients, usually because they would push themselves farther and faster than they should, which resulted in a longer recovery.

I think that as therapists, we are just as guilty of holding ourselves to a “higher standard.” I have seen colleagues and friends who are therapists give out excellent advice about the importance of seeking and accepting help and practicing good self-care, only to neglect themselves and fall into a cycle of depression, anxiety, and trauma symptoms, basically disregarding their own wise words.

[fat_widget_right]

I previously wrote an article about secondary trauma for loved ones of people who had experienced trauma. I felt it fitting to write another article for therapists, as I believe we have the potential to also experience secondary trauma. Figley (1995) defines secondary trauma as “the stress resulting from helping or wanting to help a traumatized or suffering person.”

Think about it: Most therapists see anywhere from 10 to 40 people per week.  These people are coming to us for help with their problems, which could range from normal levels of stress to severe depression, anxiety, trauma, or other mental health difficulties. We listen and offer tools they can use to overcome their challenges. They leave the sessions armed with new skills to face their lives and challenges. And what are therapists doing between sessions? I can answer from my own experience: doing notes, writing up treatment plans and assessments, returning phone calls, following up with other professionals, preparing for the next session, etc. After work, many professionals have other commitments and obligations. Life can get very busy and chaotic, and many of us consistently put ourselves last.

Therapists are just as susceptible to secondary trauma as any other person. We are not superhuman, nor do we possess mental powers that make us resilient to depression, anxiety, trauma, and other mental health challenges. Sometimes as therapists we forget this and, therefore, neglect ourselves. One study found that therapists who treat people with trauma are susceptible to the effects of secondary trauma, particularly if they do not have the appropriate training, support, and self-care (Pearlman & Mac Ian, 1995). In my experience, this applies also to therapists who are treating other mental health issues.

So what do we do about it?

• First, make self-care a priority. Pearlman and Mac Ian (1995) emphasize the importance of self-care in order to provide the best services possible while protecting the provider’s own well-being. In my experience, I am much more effective as a therapist when I am taking excellent care of myself and being aware of any secondary trauma I might be experiencing. The basics are important here: getting enough rest, eating healthy foods, getting exercise regularly, spending time engaging in leisure activities, and spending time with loved ones, to name just a few. It basically comes down to taking our own advice and implementing the self-care skills we so often suggest to people who seek our help.
• Get support from fellow therapists through supervision or consultation. Even after the days of internship are done, we can all benefit from continued supervision and consultation. Pearlman and Mac Ian (1995) state of their study, “Therapists who work with trauma survivors need supportive, confidential, professional relationships within which they can process” the work they are doing. I have found it extremely helpful and stress relieving to consult with colleagues and to even ask for supervision at times. It can be extremely validating to learn that you are not the only therapist who sometimes struggles with secondary trauma, stress, and other emotional consequences common in the helping professions. Consultation and supervision can also help a therapist to work through challenging cases by giving a new perspective and new ideas for intervention.
• Consider furthering your training. One of the most stressful situations a therapist can encounter is having a person come to you with an issue with which you are not familiar or do not feel competent treating. Of course it is good practice to acknowledge when you are not competent to treat a specific problem, and to make a referral to a colleague who might be more skilled in that area. However, sometimes furthering your education and skill set can help to reduce anxiety and stress when it comes to treating people with unfamiliar situations. Furthering your education and training can also help you to effectively treat issues with which you are familiar. The bottom line is that getting the proper training can reduce your susceptibility to secondary trauma (Pearlman and Mac Ian, 1995).
• Consider finding your own therapist. Therapists are not an exception to the fact everyone encounters difficulties in life at times. It is extremely important that we are willing to acknowledge that we are human, and to address our own issues, whether they are from the past or present. Engaging in your own therapy will ensure that you are working through your own challenges, which will make you less susceptible to the effects of secondary trauma and more available to engage in meaningful and effective therapy with people.

In conclusion, I believe one of the most important things we can do for people who see us is to take excellent care of ourselves. If we neglect our needs and ourselves, we are not able to give all we have to others. We can set a great example of self-care and avoid being susceptible to secondary trauma if we are just willing to follow our own good advice.

References:

1. Figley, C.R. (Ed.) (1995). Compassion Fatigue: Secondary Traumatic Stress Disorders from Treating the Traumatized. New York: Brunner/Mazel, p.7.
2. Pearlman, L.A., Mac Ian, P.S. (1995). Vicarious Traumatization: An Empirical Study of the Effects of Trauma Work on Trauma Therapists.  Professional Psychology: Research and Practice, 26 (6), pp. 558-565.

Palliative care is designed to provide comfort and peace to individuals facing terminal illness and end-of-life transitions. Caregivers who watch over someone in palliative care often get to spend precious moments with their loved ones in ways that would not be possible in a hospital or nursing setting. Individuals who are dying can benefit from palliative care by having those closest to them with them during their last days allowing for final wishes to be expressed and sentiments to be shared.

When death is sudden and tragic, as with an accident or unexpected illness, caregivers can experience shock and traumatic responses. Prolonged grief (PGD), also known as complicated grief, can occur when symptoms of grief are exacerbated and persist over lengthy periods of time. Experiences such as reliving the death event; being reminded of the death through mental, visual, or auditory stimuli; and even experiencing intrusive thoughts are all symptoms of posttraumatic stress (PTSD), which is not uncommon among bereaved parents and survivors of disasters or abuse.

But until now, few studies have examined whether or not caregivers of individuals who die expectedly are at risk for PTSD. To explore this issue, Christine Sanderson of Cavalry Health Care Sydney in Australia recently interviewed 32 caregivers grieving the loss of a patient who died from ovarian cancer six months prior.

The caregivers’ responses were assessed for signs of grief, emotional reactions to stimuli, language, and trauma response. For the most part, Sanderson found that the caregivers had high levels of resiliency, although some exhibited symptoms of PGD and PTSD. Specifically, trauma symptoms included strong reactions to sounds, smells, and sights that caregivers remembered from the palliative setting and also intrusive thoughts related to the death and the predeath period.

Sanderson believes that palliative care can be a cathartic experience for some, providing time for a dying person to be with family in the last days of their lives. But for some caregivers and loved ones, watching the death of someone close to them, while making no attempt to stop it, can be excruciating and lead to shock and extreme emotional distress.

Because caregivers are at increased risk for negative physical and mental health outcomes when compared to those who are not caregivers, exploration of resiliency or susceptibility after a patient’s death is essential. Sanderson added, “Skillful care of caregivers requires an understanding of the nature of their experiences, if we are to reduce traumatisation of vulnerable individuals.”

Reference:
Sanderson, Christine, et al. (2013). Signs of post-traumatic stress disorder in caregivers following an expected death: A qualitative study. Palliative Medicine 27.7 (2013): 625-31. ProQuest. Web.