Self-soothing is as natural to people as breathing. Even as infants, we quickly learn the soothing results of sucking our thumb when our mother’s nipple isn’t available. As we grow, our repertoire expands as our world expands. The soft touch of a flannel blanket or a plush toy may be our next source of comfort and emotional support. For many of us, food and drink are the go-to sources of comfort beyond our bodies.

How many happy memories are attached to good times with family and caregivers? As adults, many of the ways we make ourselves feel better are by invoking those memories through the powerful sense of smell, cooking or consuming old favorites whose aromas awaken a multisensory memory. Holidays and special occasions are built around re-creating many of these old favorites, amplifying the current experience by invoking the past.

Sometimes, however, self-soothing can become a problem. It often seems to happen when there is posttraumatic stress (PTSD) in the background, such that self-soothing behaviors are over-used and become a source of difficulty in and of themselves. Some of the ways people try to cope with the symptoms of PTSD are:

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• Eating
• Substance use
• Exercise
• Self-mutilation

1. Eating

Eating is a way that most of us self-soothe. An ice cream binge is a stereotyped way to deal with a major disappointment. Actually, both over-indulgence and over-abstention can lead to health issues.

While we’re all familiar with overeating as a possible problem, anorexia and bulimia are other ways people can use food to self-soothe. It may seem counterintuitive for someone to restrict the amount of food they take in (or keep in) as a source of self-soothing, but many experts believe this is a way of exercising control over an area of their lives which many people find satisfying as a way of combating PTSD which otherwise leaves them feeling overwhelmed and out of control. Specialists who treat eating disorders have consistently confirmed this observation (Brewerton, 2007).

2. Substance Use

Like eating, drinking to “drown our sorrows” is a well-established cultural meme. While it’s certainly not condoned by health professionals, we all know of mature individuals who have dealt with a major disappointment by overindulging in alcohol. While this can be a slippery slope toward dependency, use of other substances can be even more dangerous. The addictive nature of marijuana is widely overlooked. Drugs such as cocaine, methamphetamine, and opiates are highly addictive, and almost everyone is aware of those dangers. Tobacco use is usually initiated through cigarette smoking, which in addition to the effects of nicotine provides reinforcement through the sucking reflex, the life-giving behavior which supports our earliest efforts to sustain life. (This is why nicotine patches alone often fail to provide relief to people who want to stop smoking.)

What many people do not recognize is that these dangerous methods of self-soothing are usually turned to by people experiencing severe symptoms of PTSD who feel the need for greater comfort. It is believed that 50% to 66% percent of those who experience PTSD symptoms may also have addictive behaviors. There is a tendency to stigmatize people who have this kind of problem as being somehow morally deficient. The truth is, many have undiagnosed and untreated PTSD, usually experienced in childhood.

Running when our knees hurt, lifting weights despite an injury, not giving our bodies time to recover (like exercising seven days a week) are all ways in which we can hurt ourselves while appearing to be pursuing “health.”

3. Exercise

Everyone recognizes the importance of exercise to good health. The more the better, right? Scientists have told us there is almost no limit to the amount of exercise which is good for us—the benefits just keep adding up. However, what they are addressing is healthy, nondestructive exercise: a variety of types of exercise, including stretching, aerobic, and anaerobic exercise like that found in cross-fit regimens and yoga. This type of exercise lowers our blood pressure and improves our cholesterol and sense of well-being. It is frequently prescribed as a component of a complete PTSD recovery program. The latter is supported by the generation of endorphins when we exercise—those hormones which make us feel good after we’ve been exercising for about 20 minutes.

Like anything else which makes us feel better, it’s possible to become dependent on those endorphins and thus exercise to extremes in order to enjoy the benefits. Running when our knees hurt, lifting weights despite an injury, not giving our bodies time to recover (like exercising seven days a week) are all ways in which we can hurt ourselves while appearing to be pursuing “health.” Often, people who exercise in this way may appear to have some sort of obsessive compulsion; my experience with people who behave this way strongly suggests they are dealing with some overwhelming and irrational fear, almost always tied to some childhood trauma which resulted in PTSD.

4. Self-Mutilation

Among the many self-soothing behaviors are various forms of nonlethal self-mutilation. Usually, this takes the form of cutting behaviors. People who do this may repeatedly cut themselves with a sharp instrument, such as a knife or razor. Others may stick themselves with pins or burn themselves.

The explanation given by many people who engage in self-harm is that the pain is a distraction from the extreme emotional discomfort they are feeling. Explanations from those who do this include “to distract from painful feelings” and “to punish themselves” (Gibson & Crenshaw, 2015). Cutting or other self-mutilation gives them a way to exert control, like eating disorders, and distract themselves from their emotional pain. Several studies have found that the vast majority of people who engage in such behaviors have trauma in their background.

Finding Support

There are five types of treatment for PTSD which are recognized by the Substance Abuse and Mental Health Services Administration (SAMHSA) as being “evidence-based”: cognitive behavioral therapy (CBT), cognitive processing therapy (CPT), prolonged exposure therapy (PET), eye movement desensitization and reprogramming (EMDR), and accelerated resolution therapy (ART). The first three use a combination of education, discussion, and homework to work through the effects of PTSD. They generally require 12 to 20 sessions and are about 70% successful, on average. EMDR uses eye movements and suggestions to deal with trauma; it generally requires eight to 10 sessions and is also about 70% successful, on average. ART uses eye movements and suggestions, requires three to five sessions, and appears to be about 90% successful. As with any treatment, your mileage may vary; there is no one-size-fits-all treatment approach.

If you know someone who is indulging in extreme self-soothing, consider whether they might benefit from one of these types of treatment.

References:

1. Brewerton, T. D. (2007). Eating Disorders, Trauma, and Comorbidity: Focus on PTSD. The Journal of Treatment & Prevention, 15(4).
2. Gibson, L.E., & Crenshaw, T. (2015). Self-harm and trauma: Research findings. Retrieved from https://www.ptsd.va.gov/professional/pages/self-harm-trauma.asp
3. Kim, S.H., Kravitz, L., & Schneider, S. (2012). PTSD & Exercise: What Every Exercise Professional Should Know. IDEA Fitness Journal, 9(6).
4. The Link Between PTSD and Substance Abuse/Addiction. (n.d.). Retrieved from https://americanaddictioncenters.org/ptsd/

Complex posttraumatic stress, known as C-PTSD for short, is the result of prolonged series of traumatic experiences at the hands of someone the victim has a personal relationship with. The most common cause of C-PTSD is child abuse by a parent, stepparent, or other primary caregiver. However, it can result from a range of situations, including abusive relationships, abusive forms of imprisonment, and exploitative prostitution. C-PTSD has similar symptoms to posttraumatic stress (PTSD), but these are entwined with negative self-image, inability to control emotions, and certain personality disturbances.

The Rise of Cultural Competency

One of the most interesting aspects of working in the field of C-PTSD is the interface between cultural competency and complex trauma. Cultural competency has been a major trend within the mental health profession and, indeed, the health care field as a whole. The trend started as response to a number of studies in the 1970s which demonstrated that members of minority and marginalized communities were both less likely to seek out therapy for mental health issues and less likely to have successful treatment outcomes if they did so. While it had been naively thought that psychological research had revealed the nature of the universal human mind, experience demonstrated that many of its conclusions were highly culture contingent. What worked with people raised and acculturated in a Western cultural milieu did not always work with people from different cultural traditions.

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In response to growing awareness of this deficiency, the mental health care industry began promoting cultural competency initiatives designed to educate therapists in the cultures and mores of different minority groups. For example, learning about the differences between honor-shame societies and guilt societies allowed therapists to more effectively help people of Asian origin deal with anxiety and depression. With the expansion of culturally competent mental health services, many people gained access to effective psychotherapy for the first time and we came closer to the goal of a mental health system that serves all Americans.

However, there were two problems with the first wave of cultural competency activism, one logistical and the other more profound. The first is that the sheer diversity of human culture and the internal complexity of each branch of civilization makes it impossible for any one individual to become truly competent in all but a tiny fraction of them. True familiarity with even one culture is the work of years, even a lifetime. In short, training psychologists to achieve cultural competency in all the cultures present in a diverse country like 21st century America, then distributing them everywhere they are needed, is an impossibly complicated—not to mention expensive—task.

In practice, cultural competence training combines elements of both approaches: imparting a basic level of specific knowledge about cultural traditions that a given psychologist is likely to come across in their work so as to avoid likely pitfalls and, at the same time, cultivating a general attitude of flexibility and willingness to explore.

The second problem is that the first-wave approach to cultural competence is based on an artificial model of the world as divided into discrete, self-contained cultural units. This is an oversimplification for two reasons. First, cultural units are, in reality, composed of different subcultures. One may learn, for example, about “Chinese culture,” but there are profound differences between the culture of people from the Dongbei or Huanan regions. Similarly, the rhythms of life in Georgia and Montana are substantially different even for people who share the same ethnicity, religion, or politics. Within these subcultures, too, there are substantially different “sub-subcultures” all the way down to the level of a local town or even family. Decisions about where to draw the line between one “culture” and another are often based on arbitrary or political considerations rather than objective criteria.

Secondly, the static culture model ignores the reality of cross-cultural fertilization and the ability of individuals to cross cultural boundaries. Cultures are not static entities but dynamic, constantly evolving, compound forms, which develop precisely because individuals are able to transcend their cultural origins and incorporate new elements from others or of their own invention. Putting these two considerations together forces us to reimagine our concept of culture as a sort of spectrum, making the task of cultural competence as infinitely complex as the human experience itself.

In response to both practical and philosophical objections to the static model of cultural competence, a new approach known as cultural flexibility was developed. Instead of emphasizing specific forms of knowledge about specific cultures, the emphasis came to be placed more on openness and awareness about questioning assumptions. Instead of being a barrier to communication, with the right attitude and approach, cultural differences can be used as a tool to help the development of an effective therapeutic relationship between therapist and person in therapy. In practice, cultural competence training combines elements of both approaches: imparting a basic level of specific knowledge about cultural traditions that a given psychologist is likely to come across in their work so as to avoid likely pitfalls and, at the same time, cultivating a general attitude of flexibility and willingness to explore.

Cultural Competence and Complex Trauma

One of the most difficult and fascinating areas within the field of culturally competent psychology is the issue of trauma—and complex trauma in particular. While there are many things that are so horrific that virtually anyone would be traumatized by experiencing them, it is clear there is a great deal of cultural variation in what is considered traumatic around the world, as well as how this trauma affects people. To take a superficially extreme example, among the Mursi people of Ethiopia, about a year before marriage, which often takes place as young as 15, a young woman will have an incision of about half an inch made in her lower lip, usually by her own mother (and, of course, without anesthetic). A wooden chip will then be inserted into this incision, which is replaced with successively larger objects until, finally, a clay disk of up 20 centimeters in diameter is inserted in time for the wedding day. It is safe to assume that a typical Western adolescent would find this experience at the very least somewhat traumatic. It is also apparent that, whatever we may think of their views on the relationship between the sexes, the Mursi women are not traumatized by this procedure, or, at least, do not display the typical symptoms of traumatization.

It is of course unlikely that an American psychologist will work with a person sporting a lip plate. If it were to happen, however, it would raise many interesting questions about the nature of childhood trauma. Child abuse exists in every culture and, presumably, the Mursi are no exception, but in dealing with such a case, a therapist would have to be extraordinarily careful not to project their own culturally modulated impression of what constitutes a traumatic experience. Complex trauma represents one of the most delicate and sensitive areas for cultural competence training, and more research is needed to guide best practices regarding the universality and cultural subjectivity of potentially traumatic experiences.

References:

1. Berman S. L. (2016). Identity and trauma. Journal of Traumatic Stress Disorders and Treatment 5:2. doi:10.4172/2324-8947.1000e10
2. McFarlane, A. C. (2010). The long-term costs of traumatic stress: Intertwined physical and psychological consequences. World Psychiatry, 9(1), 3–10.
3. Tummala-Narra, P. (2014). Cultural identity in the context of trauma and immigration from a psychoanalytic perspective. Psychoanalytic Psychology, 31(3), 396-409. Retrieved from http://dx.doi.org/10.1037/a0036539
4. Wilson J. P. (2007). Cross-Cultural Assessment of Psychological Trauma. New York: Springer.

Working in the field of complex posttraumatic stress (C-PTSD) is immensely rewarding. Exploring a new field and finding more effective ways to help individuals in acute distress is as exciting as it is important. However, there are times when working in a developing and fertile field can also be frustrating. As a relatively new diagnosis that is still yet to be included in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-5), there is a paucity of reliable evidence about many of the features of C-PTSD. One of these is the connection between C-PTSD and addiction to drugs and alcohol, as well as “lifestyle addictions” to things like sex, pornography, gambling, or shopping, to name a few.

On an anecdotal level, clinicians, including myself, have observed that people with C-PTSD often have trouble regulating and controlling their use of potentially addictive substances. Excessive alcohol or narcotic consumption is frequently one of the factors that brings people to therapy, where underlying C-PTSD is discovered. There are also good reasons, some of which I discuss in this article, to suspect a causal link between C-PTSD and addiction exists. However, without further research we cannot say with certainty what the relationship between addiction and C-PTSD is, and whether the former should be understood more as an aggravating factor or a core symptom.

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The need for further research in this area is pressing. If there is one thing we know about addiction, it is that treatment is most effective when it deals with the underlying causes. Treatment methods that address problematic drinking and drug use often have an immediate effect of allowing the person to “go clean,” only to relapse half a year later because the same factors that drove the person to alcohol or narcotics in the first place are still present. A profile of the type of addictive behavior that is likely to be an expression of C-PTSD would help addiction specialists provide targeted help and make appropriate referrals.

PTSD and Addiction

While the relationship between C-PTSD and addiction awaits adequate investigation, the link between addiction and non-complex posttraumatic stress (PTSD) is much better established. Studies have demonstrated that people with PTSD are two to four times more likely to have a substance abuse disorder compared to the general population. More than 50% of people receiving treatment for PTSD have a co-occurring issue with substance abuse. Such a strong correlation suggests a definite relationship. Three suggested mechanisms for this relationship are known, respectively, as the self-medication hypothesis, the high-risk hypothesis, and the susceptibility hypothesis.

More than 50% of people receiving treatment for PTSD have a co-occurring issue with substance abuse. Such a strong correlation suggests a definite relationship.

The high-risk hypothesis posits not that PTSD leads to substance abuse and addictive behavior, but that the two are highly correlated because they often come from the same cause. People who engage in high-risk behaviors, according to this theory, are more likely to become addicted to alcohol or narcotics and are more likely to have a traumatic experience, perhaps even as a result of being under their influence.

The susceptibility hypothesis suggests that people who have a history of alcohol or drug abuse alter their brain in such a way that they are more likely to develop PTSD. It is well known that even if two people go through near-identical experiences, one may develop PTSD while the other does not. Indeed, effective screening for PTSD after traumatic events is one of the most sought-after but elusive goals of the mental health profession. According to this theory, substance and alcohol abuse should be considered as a risk factor for PTSD.

Finally, the self-medication theory, in contrast to its two rivals, suggests the causality runs from PTSD to addiction because men and women experiencing PTSD turn to drugs or alcohol as a way of relieving their distressing symptoms. Of course, while this may work in the short term, excessive use of alcohol and other substances only serves to exacerbate the problem, because the brain adapts to these chemical stimuli and demands ever greater doses of the drug to produce ever smaller highs. In short, while the person with PTSD begins by drinking or using drugs in a hopeless attempt to briefly feel good, they end up taking them in an even more hopeless struggle to feel a little less bad.

Which of these theories may be correct has massive implications for the relationship between C-PTSD and addiction. C-PTSD is the result of prolonged, interpersonal trauma, most often experienced during childhood. If the susceptibility or high-risk hypotheses are true, we would expect there to be a lesser link between C-PTSD and addiction. While there are cases of young people falling into abusive relationships after a period of drug use, it usually works the other way around. Indeed, many people with C-PTSD began their experience of trauma as small children.

On the other hand, if the self-medication hypothesis is correct, as many professionals believe, we would expect the link to be even greater. In addition to the symptoms of PTSD, people with C-PTSD also typically have negative self-image, difficulty forming relationships, and an inability to control feelings of anger or sadness (known as affect regulation). The urge to self-medicate among people with C-PTSD would therefore be even more intense.

Of course, speculation and data are two different things. Let us hope the next few years bring to light more evidence about the nature of the connection between C-PTSD and addiction.

References:

1. Ford, J. D., & Courtois, C. A. (2014). Complex PTSD, affect dysregulation, and borderline personality disorder. Borderline Personality Disorder and Emotion Dysregulation, 1, 9.
2. Lawson, D.M. (2017). Treating adults with complex trauma: An evidence-based case study. Journal of Counseling and Development, 95(3), 288-298. Retrieved from http://doi.org/10.1002/jcad.12143
3. McCauley, J. L., Killeen, T., Gros, D. F., Brady, K. T., & Back, S. E. (2012). Posttraumatic stress disorder and co-occuring substance use disorders: advances in assessment and treatment. Clinical Psychology: A Publication of the Division of Clinical Psychology of the American Psychological Association, 19(3), 10.1111/cpsp.12006. Retrieved from http://doi.org/10.1111/cpsp.12006
4. McFarlane, A. C. (2010). The long-term costs of traumatic stress: Intertwined physical and psychological consequences. World Psychiatry, 9(1), 3–10.
5. Sar, V. (2011). Developmental trauma, complex PTSD, and the current proposal of DSM-5. European Journal of Psychotraumatology, 2, 10.3402/ejpt.v2i0.5622. Retrieved from http://doi.org/10.3402/ejpt.v2i0.5622

Dissociation was first described more than a century ago. It was not until more recently, though, that the concept became a standard part of the psychological lexicon. For many people, it is still shrouded in mystery. Terms such as dissociative identity, “dissociative fugue,” or “depersonalization” sound opaque, even intimidating. This can make it difficult for those experiencing dissociation to understand what they are going through and seek appropriate help.

Better-known concepts such as anxiety or depression may be easier to understand because they are extreme versions of universally recognized feelings. Someone who has not struggled with clinical depression or anxiety can fully appreciate how it feels. But to some extent we can extrapolate from common feelings of sadness and nervousness to draw a picture of what these conditions are. By comparison, dissociation may be an alien and unfamiliar experience to many people.

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However, while this may not be generally recognized, dissociation is actually something experienced by many—perhaps even the great majority—of people on an occasional basis. Have you ever walked somewhere and got to your destination realizing you remember nothing from the trip? Have you ever been in a boring meeting and found yourself daydreaming, only “awakening” 15 minutes later to find you have no idea what was discussed? Have you been engrossed in a book, only to suddenly realize you can’t remember what you just read? Even if the answer is no, you probably know plenty of people for whom the answer is yes.

All of these are miniature examples of dissociation which occur in day-to-day life. What they share is an experience of detachment, disconnection, or dissociation from the surrounding environment. Such experiences need not be indicative of anything wrong. They may well not even be unpleasant. But when they are frequent, uncontrollable, or a source of distress, they become problematic.

Dissociation is a common response to trauma. Many people who have been through traumatic experiences find that they are temporarily unable to remember what happened, even when they have feelings of fear, anguish, or grief as a result of their experiences. Others have a somewhat opposite experience: they can remember the incident clearly, but they feel detached from it, as if it happened to someone else or they watched it in a movie.

In many cases of posttraumatic stress (PTSD), the person experiences dissociation when confronted by stimuli that remind them of the traumatic experience. They “tune out” of memories that are too painful to confront head-on. In more mild cases, this coping mechanism is not particularly problematic, but it becomes so when dissociation is a habitual response to everyday occurrences. Therapy for PTSD typically consists of adopting strategies to cope with these stimuli without triggering dissociation.

One of the key links between PTSD and complex posttraumatic stress (C-PTSD), dissociation plays a central role in diagnosing and understanding C-PTSD. As I have discussed in other articles, the concept of C-PTSD was developed to understand personality conditions that had many features associated with PTSD.

When the trauma is drawn out over a number of years, dissociation becomes a way of life. Once learned, it is a fixed part of the personality that asserts itself long beyond the original dangers that prompted it.

While similar to PTSD in many ways, C-PTSD has features that make it unique. This pattern of similarity and difference is the product of their overlapping but distinct causes. PTSD is the result of a small number of impersonal dramatic and traumatic incidents (often just one), such as road accidents, witnessing a violent death, or being held hostage. The different pattern of C-PTSD comes from the fact it results from a sustained period of traumatic incidences (which, taken individually, may not be significant enough to produce symptoms of trauma), usually in childhood, which happen at the hands of someone the victim has a personal relationship with—often a primary caregiver such as a parent.

In C-PTSD, dissociation may play an even more crucial role than it does in PTSD. Children are particularly likely to engage in dissociation because of their lower emotional maturity and limited experience. Children have little or no ability to control their situation. They are reliant on caregivers for the primary needs of food, shelter, nurturing, and safety. In response to abusive or disturbing behaviors at home, where active resistance is out of the question, the child will find that the most natural and safe response to cope with the abuse is to detach, to go through these traumatic experiences without really experiencing them.

When the trauma is drawn out over a number of years, dissociation becomes a way of life. Once learned, it is a fixed part of the personality that asserts itself long beyond the original dangers that prompted it. This is an illustration of the principle that C-PTSD is essentially a learning process gone awry as a consequence of the child developing in a dangerous environment.

Forms of dissociation resulting from C-PTSD can be extreme. A common symptom is fragmented personalities. Growing up, the child may have developed different personality states that were called upon in abusive situations. These multiple personalities may persist into adulthood and are triggered by situations reminiscent in some way (often tangentially) of the abusive situation. When these supplementary personalities take over, the person may do things that are out of character for their main state, even things they find abhorrent. In the most extreme cases, these dissociative states may persist for days on end, leaving the person with no memory of what they have been doing during the interval.

Learning to gain control over dissociation and, in particular, mitigate negative effects that may result from dissociative episodes is a central part of therapy for C-PTSD.

References:

1. Ford, J. D., & Courtois, C. A. (2014). Complex PTSD, affect dysregulation, and borderline personality disorder. Borderline Personality Disorder and Emotion Dysregulation, 1, 9. Retrieved from http://doi.org/10.1186/2051-6673-1-9
2. Lawson, D.M. (2017). Treating adults with complex trauma: An evidence-based case study. Journal of Counseling and Development, 95(3), 288-298. Retrieved from http://doi.org/10.1002/jcad.12143
3. McKinsey Crittenden, P., & Brownescombe Heller, M. (2017). The roots of chronic post traumatic stress disorder: Childhood trauma, information processing, and self-protective strategies. Chronic Stress, 1, 1-13. Retrieved from https://doi.org/10.1177/2470547016682965
4. Sar, V. (2011). Developmental trauma, complex PTSD, and the current proposal of DSM-5. European Journal of Psychotraumatology, 2, 10.3402/ejpt.v2i0.5622. Retrieved from http://doi.org/10.3402/ejpt.v2i0.5622
5. Tarocchi, A., Aschieri, F., Fantini, F., & Smith, J. D. (2013). Therapeutic assessment of complex trauma: A single-case time-series study. Clinical Case Studies, 12(3), 228–245. Retrieved from http://doi.org/10.1177/1534650113479442

Some of the most powerful work I have seen accomplished in therapy involves a person reclaiming parts of themselves that they have disowned. Splitting off parts of ourselves, specifically parts of our younger selves, is a common issue that people seek to resolve in therapy, even if they are not fully conscious of it.

In fact, many therapy theories and techniques use this concept as a way of addressing concerns. Below are a few ways of describing this concept.

• Internal Family Systems model: Refers to this concept as exiled parts created out of traumatic experiences. These are parts we are afraid to look at and expose (Schwartz, 2009). [fat_widget_right]
• Object relations therapy: Refers to this as splitting, defined as the failure in a person’s thinking to bring together both positive and negative qualities of the self and others into a realistic whole (Hamilton, 1990).
• 12-step program for addiction: In alcoholism-afflicted/dysfunctional families (2006), one of the main issues is considered to be the inner child that has been hidden because of shame, abuse, or fear. To be free from addictive behaviors, reconnecting with the inner child is a necessary part of treatment.
• EMDR therapy: In this approach, Shapiro (2012) points out that memories, especially traumatic ones, are not integrated with the rest of the general memory networks. As a result, these memories can feel “frozen” or “stuck in time” and no matter how much time passes, bringing them up again can be painful—thus, often, we don’t deal with traumatic memories. The eye movement desensitization and reprocessing (EMDR) approach helps a person to take these memories and reprocess them into general and adaptive memory networks.

So how do you know if there might be a split-off part of yourself? One way is by recognizing there might be denial about the past in the present. This can look like, as examples, refusing to admit or acknowledge childhood experiences; trivializing behavior or remarks that were hurtful; or attempting to explain away the behavior of others or offer excuses.

The overall goal at the end of this work should be integration. Integration means being able to own all parts of yourself, whether “good” or “bad,” and understand how they make you the person you are today.

This also presents itself in how we describe ourselves when we were younger. For example, a statement such as, “I don’t know who that person was,” or feelings of intense shame about the person you were in the past, can be a sign that you have cut off parts of yourself. Another strong indication of this is if you avoid people, places, or things that might bring up memories from the past.

When you or your therapist has recognized you have cut off a part of yourself, there are many tools you can use to begin recognizing those cut-off parts and work toward healing. Below are some ways to begin identifying and connecting with parts of yourself:

• Looking at photos of yourself from the past.
• Listening to music from that time period.
• Giving yourself affirmations such as, “I will love all parts of myself unconditionally,” “I will protect myself to the best of my ability,” or “I will take time to integrate all parts of myself into my life experience.”

The overall goal at the end of this work should be integration. Integration means being able to own all parts of yourself, whether “good” or “bad,” and understand how they make you the person you are today.

It is important to note that reclaiming split-off parts is difficult work that can take a long time. If you are thinking of attempting this work for yourself, consider enlisting the help of a licensed professional or finding a group therapy setting that can help you through this process.

References:

1. Adult Children of Alcoholics World Service Organization. (2006). Alcoholic/dysfunctional families. Torrance, CA: Author.
2. Hamilton, N.G. (1990). Self and others: Object relations theory in practice. New York, NY: Rowman & Littlefield Publishers, Inc.
3. Schwartz, R. (2009). Instructor’s manual for internal family systems therapy. Retrieved from http://www.psychotherapy.net/data/uploads/5113ce91c0a4d.pdf
4. Shapiro, F. (2012). Getting past your past: Take control of your life with self-help techniques from EMDR therapy. New York, NY: Rodale Books.

Nowadays, people seem to be very aware of trauma, complex trauma, and both the existence and effects of posttraumatic stress (PTSD). This increased awareness can only be a good thing, but there’s one significant omission. I don’t often hear people talking about the concept of posttraumatic growth, or what could be considered the “silver lining” of trauma.

Far from considering the possible positive impact trauma could have on a person, modern culture seems to in fact be fixated on protecting people from hardships of any kind. In this litigation-minded society, people are cautious about every little thing. Children can’t play tag on the school playground or climb trees anymore because they might get hurt. People are preoccupied with safety, in Western cultures in particular.

Considering personal safety is, of course, important. But with the type of mindset that encourages children to see the potential danger in every action, children are then more likely to grow up being afraid to take any risks, for fear they might fall down and get hurt. The fact is, they might fall down and get hurt. But falling, even pain—neither are insurmountable experiences. Without pain, people cannot grow. It is the hardships in life that mold us and build our character and inner sense of confidence.

How Hardship Can Help Us Grow

Of course I am not saying people need to experience extreme forms of trauma in order to learn and grow. However, I do believe people benefit from facing hardship and difficulty, and the intrapersonal struggles we often undergo in order to persevere through these life challenges help us become strong enough to face them. With trauma, then, often comes the development of strength of character and inner conviction of survival and victory. [fat_widget_right]

“Although the world is full of suffering,” Helen Keller once said, “it is also full of the overcoming of it.” Consider that we cannot learn to get up until we fall down. Our confidence grows as we watch ourselves endure through and triumph over hardship.

Traumatic experiences are far-reaching and often affect all aspects of a person, including physical health, emotional state, and mental well-being. These effects are likely to include both immediate impact on a person’s life and daily function as well as long-term effects. An individual’s physical body, including their brain chemistry, is often radically changed—at least for a while.

The effects of trauma, whether they are short-term effects or last for months or even years, often include dissociation, increased negative thinking, flashbacks, triggers, emotional dysregulation, and changes in the brain’s structure, among others. In short, traumatic events transform a person.

When a person experiences any type of trauma (personal or otherwise), they often lose part of the self. Qualities such as trust, innocence, gullibility, sense of safety, and beliefs in the self and/or others may be shattered. Only once the initial shock of a traumatic experience wanes can the affected individual begin to grieve.

But falling, even pain—neither are insurmountable experiences. Without pain, people cannot grow. It is the hardships in life that mold us and build our character and inner sense of confidence.

Grieving is nature’s best way to heal trauma. Just like a broken arm needs healing, so does a broken psyche. But the grief process is just that—a process, not a destination. It can be described as a spiral: the feelings are experienced over time as healing takes place. Certain triggers may cause the survivor to be reminded life is not safe, and anxiety attacks may flare up when something akin to the original trauma happens.

But with rest, support, self-care, inner compassion, and other steps known to help the process of grief (journaling, crying, talking, expressing feelings through art, and being kind and patient with the self, among others), healing and posttraumatic growth are both possible.

Working Toward Posttraumatic Growth

If you have experienced trauma yourself, or if you are a counselor who wants to help someone you are working with understand how to make sense out of a trauma, you can ask questions such as, “How has this experience changed you?” “What wisdom do you have about life now that you didn’t have before this traumatic event occurred?” “What is helping you heal?”

Thought-provoking questions such as these can help people ponder the effects trauma has had on them. People often make meanings out of difficult life experiences through epiphanies. It would be difficult to “force” an epiphany, but you might ask, “Have you had any epiphanies related to your experience?”

I believe the most important way to transform trauma into growth is to find hope. If you have been victimized, finding something positive to hold on to is considered an essential aspect of recovery. This may not be easy, especially not at first, but it is imperative for a contented life. The discovery or regrowth of hope can lead to posttraumatic growth.

Though in the early wake of trauma, it may be difficult for some survivors to imagine any positive outcome, much less growth, it is possible for people to develop strengths and experience other positive effects after a traumatic experience, especially with the help of a compassionate and qualified mental health professional.

These “silver lining” benefits of trauma might include:

• Resilience, inner strength, grit
• Wisdom
• Increased empathy and compassion for others
• Humility
• Motivation
• Becoming closer to one’s god/increased spirituality or spiritual feeling
• Personal confidence

It should be emphasized it is never advised to push yourself or others to hurry through the grief process in order to arrive at the “meaning making” stage. The process of making meaning is not something to be forced. It is something to behold. It becomes apparent.

The process toward posttraumatic growth is not fixed, and each person may experience growth in different ways. However, what I consider the three necessary steps toward this growth are as follows:

1. Grieving who you were and how you viewed reality prior to the traumatic event(s)
2. Making meaning out of your experiences
3. Choosing hope

An Attitude of Hope

Victor Frankl, neurologist, psychiatrist, Holocaust survivor, and author of Man’s Search for Meaning said, about overcoming trauma, “The one thing you can’t take away from me is the way I choose to respond to what you do to me. The last of one’s freedoms is to choose one’s attitude in any given circumstance.” [amazon_affiliate]

Frankl experienced great horrors when imprisoned in different concentration camps in Nazi Germany. After his rescue he went on with his life and became a great philosopher. He learned, in spite of everything taken from him, he still possessed a small glimmer of power—over his own attitude. He understood the ability to find his autonomy in that one area alone was enough for him to sustain any trauma.

Hope is an attitude. Hope is something that can be developed. When I talk about hope in this context, I am not talking about a hope such as “I hope tomorrow is a sunny day.” I am talking about the type of hope where you want something to happen, the deep abiding hope for a positive outcome, the hope that life will be good. This is the type of hope that is determined and knows, no matter what troubles befall a person, there is always a silver lining. This is positive anticipation. The feelings involved in this type of hope are ones of optimistic expectation and gratitude.

Helping Trauma Survivors

Counselors can help trauma survivors by constantly reminding them things will be better. “This, too, shall pass” and “Better days are coming.” It is important to remember each time you meet with a person who has survived trauma to tell them something encouraging. Be the hope that person may not be ready to own. Think of yourself as “hope personified.” The people you work with will pick up on your personal attitudes toward them and their tragedy.

You can even ask the person you are working with, “How can I encourage you today?” The person will often be able to tell you some specific thing that will be helpful to them. For example, they might say something like, “Tell me I’m going to get back to normal again.”  You can reply with an encouraging response such as, “You may not be the same, but you will heal, and you will be better.”

Always offer hope to the people you are working with, until they are able to own it themselves.

“It is an absolute human certainty that no one can know his own beauty or perceive a sense of his own worth until it has been reflected back to him in the mirror of another loving, caring human being.” —John Joseph Powell, The Secret of Staying in Love

“Invisible threads are the strongest ties.” —Friedrich Nietzsche

There’s a lot more to trauma than meets the eye—or the general public’s awareness—and it’s deeply related to love and connection.

When many people think of trauma, they tend to think about shock trauma: a single, overwhelming incident that’s larger than our ability to cope. Examples include natural disasters, motor vehicle accidents, sexual assault, animal attacks, and war.

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On the other hand, developmental trauma comes from something that happens improperly during childhood. It is often subtle and may happen over a long period of time. It involves not receiving the necessary supports for the young nervous system to mature and develop in the way it needs to. Some of these supports are material, of course, but many are relational: having to do with the overall quality and nuances of important relationships, especially with parents.

You can think of it like incorrect or missing ingredients in a recipe: The cake is baked, but it hasn’t risen all the way. Of course, a cake is pretty much finished after it comes out of the oven. The good news for us is, unlike the cake, our nervous system is always primed and waiting to recover what it needs. Thanks to neuroplasticity, our growth and development are lifelong.

In developmental trauma, the biggest and most common missing “ingredient,” by far, is that of deeply and consistently feeling love and connection. I’m not talking about watching your parents behave toward you in a responsible and self-sacrificing manner and then deducing they must love you. No, I’m talking about feeling it deep in your bones that you are loved—indeed, treasured. This bodily felt sense allows us to sink into a sense of safety and well-being. It is truly traumatic to not receive this basic ingredient; we need it to develop and maintain a stable sense of ourselves and of safety.

With love being so basic, how is it so many of us end up without enough of it?

It’s been my experience that:

• Some parents deeply love their kids, but they don’t know how to show (embody) it because they never had this from their own parents.
• Some parents love their kids, but their own life circumstances are too chaotic for them to embody it or be consistent about it with their children. This happens frequently when addiction or other chronic conditions strike the family.
• Some parents simply don’t have the capacity to love, usually due to their own developmental traumas.
• Some people don’t have parents who are in their lives.

Long the fodder of songwriters and poets, our desire for love also has a deeply biological basis. It goes beyond simple reproduction (which is accomplished in reptiles without a shred of sentimentality, as far as we can discern). Basically, the physical origin of love lies in our mammalian biology. We are not lizards! Think about our fellow mammals: puppies, rabbits, hamsters. They are warm and cuddly, and many, if not most, of them prefer company.

As Dr. Stephen Porges explains, reptiles have slow metabolisms; that’s why they are cold, and why snakes can go weeks without eating. Mammals have much faster metabolisms, so we need to eat more frequently. This need to extract more nutrients from the environment requires a more complex survival strategy—and that’s why most of us tend to stick together. It is part of our most essential survival wiring to stick together and form deep, satisfying bonds with other humans.

For us humans, being (or feeling) alone is biologically stressful, and may lead to poor health outcomes including earlier death. Consider:

• In prison settings, solitary confinement is often considered to be a form of torture. Too much of it can cause the person to become psychotic.
• The Atlantic has a series of articles about isolation and loneliness. Research indicates people, animals, insects, and even cells experience health issues and die more quickly in isolation.
• Dr. Dean Ornish is a cardiologist in San Francisco. He has a reputation for being able to save heart patients whom other physicians have been unable to help. He considers his patient support groups an essential part of his formula for success.
• Check your experience: Try to recall the last time you were pleasantly touched by another human being in a way that felt both safe and consensual. If you are unable to access such a memory and you’re an animal lover, you could recall cuddling with a dog or a cat. How did this experience make you feel in your body? Many people report a pleasant sense of warmth, full embodiment, and well-being. Such experiences are accompanied by physiological markers of reduced stress, such as lowered heart rate, blood pressure, and cortisol.

Despite the growing body of literature to the contrary, some people convince themselves they’re okay alone or mostly alone. Some even feel they’re better off that way. Others make do with surface-level interactions, but they don’t share any of their private or intimate feelings very often. Men especially tend to be socialized into the idea it’s not okay to share their deeper feelings (this idea tends to cause them great suffering, which they then have to disconnect themselves from).

In my experience, the reason some folks teach themselves to “make do” with relational crumbs is because they have experienced unbearable pain in their attachment relationships. Such experiences create an unsolvable bind: the person must deny themselves this vital “nutrient” in order to survive. Being alone might be lonely, but at least it feels safe. And so they bury the deep need for love and connection, or they find bits of it by caretaking others and then fleeing when the relationship becomes too intense. However, as Jeremy McAllister notes in his brilliant article Ending the Anxious Avoidant Dance, Part 1: Opposing Attachment Styles, “The most avoidant among us, while perhaps giving up on the possibility (or dissociating from it most of the time), still desire connection outside of self.” It’s in there, somewhere, behind those seemingly impenetrable defenses.

This strategy of forging a life mostly or entirely by oneself often requires some kind of addiction in order to stay disconnected from these intolerable feelings. Common examples include addiction to work, sex, various mood-altering substances, and physical exercise. None of these activities are inherently bad, of course; it all depends on how one approaches them.

The corollary to “love is dangerous” is often “and I’m not allowed to have any needs.” This is because “having needs makes me vulnerable” in that needs are potential pathways to even more intolerable pain: the pain of punishment, disappointment, rejection, or of having to revisit and feel the old, buried, unmet needs. McAllister refers to this as “self-sufficient, unsupported life and its accompanying sense of scarcity and fatalism—a frozen mix of giving up and hanging on, not taking chances.” These are defenses against pain that is truly intolerable. Those of us who have ever loved an avoidant person would do well to keep this in mind, regardless of the outcome of the relationship: they are suffering from the ghosts of old, truly intolerable pain.

A dear friend of mine struggled with love and connection throughout his life. He likened his struggle to being alone on a cold beach in wintertime and approaching a campfire: “You’re cold and lonely and you look down the beach, see the light and warmth, hear the conversation and laughter. So you approach, and then you’re in the warmth and the laughter, and it feels wonderful. But then you get too close, or the fire flickers, and the light and the heat burn you. So you retreat back into the cold, where it’s lonely and quiet but at least things are calm and they don’t burn you. But then eventually, the loneliness draws you back in … and you approach again, cautiously … and the whole thing starts all over.”

So, it seems that human love and connection are vitally important but intensely complicated. No one ever said it was easy being human, and I believe deep relational difficulties are a major cause of human struggling. So, then, what on earth do we do about all this?

Life isn’t forever, and a common regret at the end is that of having bypassed some risks that could have really paid off, especially those related to connecting with others. It’s a missing out on what could have been but never was. So why not take that risk?

My thought is, the same trauma that harmed us can also be a window into deep healing. It may feel easier to stay in avoidance, but we have to start taking the risk to be more vulnerable, even if only in baby steps.

At the time of the 1994 Northridge earthquake in Southern California, I was living in West Los Angeles and working as an in-home supported living counselor. Wanting to be of service, I drove carefully around the city to my clients’ houses a few hours later. Aside from the obvious rubble and other physical disruptions, I remember one thing very clearly: people were wide open to each other. It was really beautiful. On the streets, in the grocery stores, people of disparate ethnic groups, gender, age, everything—they were all hugging each other, asking each other if they were okay, telling their earthquake stories. The difference was dramatic: the traumatic event had cracked their usual defenses.

Relational issues can be just as powerful. For example, I’ve long felt grief cracks our hearts wide open. I am never so deeply appreciative of my friends as I am after I’ve lost one.

In my years as a clinician, I have seen that, in a strange and unpredictable way, the very trauma that injured us can also be the doorway into a deeper healing and happier way of life. Now, this requires courage—so much courage. I’ve never seen such bravery as I see in the trauma survivors who come to work with me. Every day, I sit with them and they discover things that feel bad in their experiences, in their bodies. I ask them, “That tightness in your chest, that pit in your stomach: can you sit with that and feel it? Can we sit with it together? Let’s see what it has to say.” This is the stuff many people spend their lives avoiding; yet here these folks are, staring it right in the face. Their systems learn to tolerate the trauma, metabolize it, and then organically move into a much happier state of being.

Life isn’t forever, and a common regret at the end is that of having bypassed some risks that could have really paid off, especially those related to connecting with others. It’s a missing out on what could have been but never was. So why not take that risk? By which I mean, be the change you wish to see in the world. Take the risk of offering kindness where anger wants to jump in. Open your heart to the widest extent you can. If it won’t open, get yourself some kind of support with that: attending therapy, meeting with a spiritual leader, obtaining a volunteer job, a dog, even a garden. We’re all in this together, and life is too short to keep our hearts closed and later regret it.

And in the end, love is worth it.

“I give thanks for life. I honor life.” —Peter Levine, World Trade Center 911 survivor video

“Sometimes reaching out and taking someone’s hand is the beginning of a journey. At other times, it’s allowing another to take yours.” —Vera Nazarian

References:

1. Abrams, L. (2013, April 24). How people and animals in isolation die sooner. The Atlantic. Retrieved from https://www.theatlantic.com/health/archive/2013/04/how-people-and-animals-in-isolation-die-sooner/275071
2. Heiss, J. (2015, July 2). Solitary confinement isn’t punishment, it’s torture. The Guardian. Retrieved from https://www.theguardian.com/commentisfree/2015/jul/02/solitary-confinement-isnt-punishment-its-torture.
3. Helper, S.S. (2017, August 5). So lonely, I could die. Retrieved from https://www.socialworkhelper.com/2017/08/05/so-lonely-i-could-die
4. Levine, P. (2002). Sharon: World Trade Center 9/11 survivor video. Summarized at https://traumahealing.org/wp-content/uploads/2017/01/Demo-Descriptions-2016.pdf
5. McAllister, J. (2017). Ending the anxious-avoidant dance. Retrieved from https://www.goodtherapy.org/blog/ending-anxious-avoidant-dance-part-1-opposing-attachment-styles-0518174
6. Ornish, D. (1995). Dr. Dean Ornish’s program for reversing heart disease: The only system scientifically proven to reverse heart disease without drugs or surgery. New York: Ivy Books.
7. Porges, S. (2011). The polyvagal theory. New York: Norton and Company.
8. Scheff, W. (2001). Personal communication.
9. Trudeau, M. (2010). Human connections start with a friendly touch. Retrieved from http://www.npr.org/templates/story/story.php?storyId=128795325
10. Ware, B. (n.d.). Regrets of the dying. Retrieved from http://www.bronnieware.com/blog/regrets-of-the-dying

A primary focus of therapy is healing from past traumas and making attempts to improve the parts of ourselves we find unsatisfactory. There’s clearly a need to address these issues to move toward a more fulfilling life. But have you ever considered that reliving past successes could create a similarly negative impact?

The opposite of replaying a terrifying or life-threatening event would be the fixation on a better time in an individual’s life. Ironically, I’ve observed this type of over-attachment to create nearly as many barriers as a trauma. Instead of being haunted by nightmares and flashbacks commonly associated with trauma, individuals with this type of fixation exist in a persistent state of longing to repeat or restore what once was. This results in a distracted way of showing up to the present moment and often creates a warped sense of reality.

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These individuals may continually revisit a fixed place in the past. On the surface, becoming engrossed with a perceived positive memory or time doesn’t seem particularly risky. However, when this type of fixation goes beyond nostalgia, it can create the illusion the present is not as worthwhile. The resulting emotions may include shame, sadness, anxiety, and a sense of hopelessness.

Being overly fused with an idealized past frequently manifests as depression. The archetypal movie character is the aging athlete whose “glory days” are long gone. Substance use or some other maladaptive form of coping is frequently used in an attempt to ease the discomfort of being separated from the “golden era” of one’s life. For many, a telltale expression often used when referring to a romanticized past are phrases such as “those were the good old days” or “life was so much easier back then.”

Whether it’s thinking too highly of yourself or obsessively replaying the highlight reels of your life, these mind-sets both serve to rob you of the potential to create a more meaningful existence. In comparison to trauma processing, it’s easy to miss this more subtle, yet still harmful, way of relating to the past.

I can relate to this type of rumination, especially when present circumstances feel especially challenging. I occasionally find myself reflecting on memories of childhood, high school, or college. Those times are associated with less pressure, reduced responsibility, and fewer obligations. But if I’m being honest, those chapters all had a unique set of hardships that can too easily be glossed over without careful introspection.

The truth is every segment of our lives comes with its own set of distinct problems and challenges. Life ebbs and flows, vacillating between times of difficulty and times of peace or triumph. However, this idea of having an expiration date for achieving the best version of yourself or your life can be extremely limiting. It generates a perception and attitude you can never measure up to what once was or who you once were, therefore why try to create meaning and purpose in the present?

This same concept can be extended to the overemphasizing of one’s positive attributes, often casually referred to as narcissism. An inflated sense of self may seemingly be a better alternative than a devalued sense of self, but both create barriers for growth. Those with grandiose views of self do not see the need for self-improvement, severely limiting their ability to accurately process reality. They also generally lack empathy for others, which has a high cost in terms of building deep and authentic relationships.

Whether it’s thinking too highly of yourself or obsessively replaying the highlight reels of your life, these mind-sets both serve to rob you of the potential to create a more meaningful existence. In comparison to trauma processing, it’s easy to miss this more subtle, yet still harmful, way of relating to the past. Striking a balance between being able to reflect on fond memories and shifting attention back to the present is key. Cultivating the ability to hold both your strengths and your flaws lightly is more workable than overidentifying with either.

If you feel stuck in the past and unable to find meaning or purpose, I encourage you to process this with a mental health professional.

A survey conducted in 2011 by The National Intimate Partner and Sexual Violence revealed one in five women and one in 71 men will be raped during their lifetime (Black, Basile, Breiding, Smith, Walters, Merrick, & Stevens, 2011). Additionally, one in four girls and one in six boys will be sexually abused before the age of 18 (Finkelhor, Hotaling, Lewis, & Smith, 1990). Given these alarmingly high numbers, it is not unlikely a survivor of sexual trauma may disclose to you in your lifetime.

Therefore, it is paramount to be prepared, to arm yourself with guidance and direction that will allow you to handle such a situation with care. Most survivors of sexual trauma will share what happened to them with at least one person in their personal network, such as a close friend, family member, or significant other. Survivors may selectively confide in others about their trauma, but I believe it is essential everyone has access to education and information about how to best respond—and how NOT to respond—in the event someone close to you discloses their experience. [fat_widget_right]

Responding to Disclosure in Positive Ways

Sadly, research has shown survivors often receive negative or unsupportive reactions when disclosing trauma. Some of these responses often include blame, criticism of their actions at the time of the assault, questioning if an attack was indeed rape, and so on. These negative responses can have detrimental outcomes for survivors and often cause further hurt and emotional pain.

Survivors often receive negative or unsupportive reactions when disclosing trauma. … These negative responses can have detrimental outcomes for survivors and often cause further hurt and emotional pain.

I previously wrote an article in which I focused on ways people can offer support to survivors of sexual trauma who confide in them. This article highlighted ways to use the BRAVE communications model to respond to disclosure with care and sensitivity. I was struck by how many people reached out and expressed they were still afraid to say the wrong thing during sexual assault disclosures. I was touched by the number of people who demonstrated such a strong commitment to not saying something unsupportive during this sensitive time. Consequently, I felt compelled to write a follow-up to discuss in detail what never to say or do when someone confides the sexual trauma they have experienced.

Since negative social responses often thwart a survivor’s recovery and may produce more posttraumatic stress symptoms (Ullman & Peter-Hagene, 2014), it’s critical you are thoughtful in your responses to these situations. One of the key elements to handling disclosure moments with support is knowing what never to do or say. You can prepare yourself beforehand by developing your awareness of the dialogue and behaviors to avoid, and this essential first step will help ensure any survivors of sexual violence who share their story will receive a positive experience when they decide to do so.

Preparedness can go a long way toward fostering healing for survivors. The list below offers guidance and a starting place, though it may not be all-inclusive, for people to develop understanding of how not to react when disclosed to:

1. Avoid reacting with disbelief.  One of the most detrimental ways to respond is to show you don’t believe the survivor. Studies have shown false reports of rape only account for about 2-8% of reports. These statistics are similar to any other crime (Lonsway, Archambault, & Lisak, D., 2009). We certainly don’t doubt or question people who tell us they have had their home burglarized or their wallet stolen. Sexual violence should be no different.
2. Avoid reacting with blame, criticism, or judgment. Don’t ask “why” and “what” questions, as these are only likely to perpetuate victim blaming and contribute to the survivor’s negative thoughts, feelings, and emotions. Questions such as, “Why did you go alone to the apartment?” “Why were you drinking alcohol?” “Why did you get drunk?” “What were you wearing?” “Why did you start being physically intimate if you didn’t want to have sex?” “Why didn’t you fight back?” “Why didn’t you scream?”are not at all helpful. In no circumstance is a survivor of sexual violence to blame for the crime. “Why” and “what” questions, however, have the potential to communicate to the survivor they are responsible for the act of another person, which, again, is never the case. Only the perpetrator of the sexual assault is to blame. In general, use extreme care when considering a why/what question in this circumstance.
3. Avoid negative reactions. Being negative when a survivor shares their trauma story can have consequences for the survivor. It’s generally not advisable to tell survivors they shouldn’t report the incident or tell them their attacker is unlikely to be caught even if they do report the attack. Neither is telling a survivor they shouldn’t share with any more people a positive reaction. You may say this because you care and worry how others might react to hearing of the assault, but the atmosphere of negativity created is generally unhelpful and unsupportive. It is also critical survivors are not told what to do or how to handle the aftermath of the attack, as this effectively continues to take away or limit their sense of power and control. Survivors need to feel empowered. This means they should make their own choices about how to handle the crime, including decisions on whether or not to press charges.
4. Don’t treat survivors differently. Treating survivors differently, such as by acting as if they are damaged in some way or now defective, can be damaging to their wellness and recovery. Survivors need to know they have a consistent and stable support system, so if you begin avoiding a person who has disclosed to you, this can be hurtful. If you aren’t sure how you can help them, you can always ask!
5. Avoid minimizing what happened. Never tell survivors to just get over it or that what happened is in the past. Other unhelpful things to say to survivors include, “You don’t need professional help;” “It was only sex;” or “Are you sure it was really rape?” “Sexual assault is about power and control, not sex.” These types of questions and statements are attempts to reduce what has happened to the survivor. The truth is, sexual violence is a common traumatic event frequently leading to PTSD in survivors, a majority of whom are women. Sexual trauma is not to be reduced and minimized, as the effects of this kind of trauma include negative emotional and physical consequences often warranting professional assistance. Encouraging survivors to seek mental health care for trauma can promote healing.

If a survivor of sexual assault confides in you, avoid the above reactions to increase your chances of providing survivors with a positive disclosure experience. This sensitivity will continue to help dismantle rape culture, make it more comfortable for survivors of sexual violence to share when they feel appropriate, and validate a survivor’s decision to place their trust in you. Healing takes time, but you can help the process—one moment at a time!

References:

1. Black, M. C., Basile, K. C., Breiding, M. J., Smith, S .G., Walters, M. L., Merrick, M. T., Stevens, M. R. (2011). The National Intimate Partner and Sexual Violence Survey: 2010 summary report. Centers for Disease Control and Prevention. Retrieved from http://www.cdc.gov/ViolencePrevention/pdf/NISVS_Report2010-a.pdf
2. Finkelhor, D., Hotaling, G., Lewis, I. A., & Smith, C. (1990). Sexual abuse in a national survey of adult men and women: Prevalence, characteristics and risk factors. Child Abuse & Neglect 14, 19-28. doi:10.1016/0145-2134(90)90077-7
3. Lonsway, K., Archambault, J., & Lisak, D. (2009). False reports: Moving beyond the issue to successfully investigate and prosecute non-stranger sexual assault. The Voice, 3(1), 1-11.
4. Ullman, Sarah E.; and Peter-Hagene, Liana. (2014). Social reactions to sexual assault disclosure, coping, perceived control and PTSD symptoms in sexual assault victims. Journal of Community Psychology, 42(4): 495–508. doi:  10.1002/jcop.21624

Eastern traditions have long recognized the importance of the mind-body connection for general wellness, and Western thought is beginning to follow suit. An increasing amount of research is emerging to support this link. Yoga in particular has become especially popular in recent years as a way to facilitate the mind-body connection and is now one of the most widely practiced forms of complementary health care in the United States.

Demonstrated to have benefit in the treatment of numerous physical health conditions and mental health concerns, stress and trauma-related issues among them, yoga is utilized by many to cultivate mindfulness through a combination of physical movement, breathing exercises, and relaxation. Yoga therapy, in fact, is a growing field of mental health treatment.

Yoga and the Stress Response

Many studies have observed the effect of yoga on the fight-or-flight response, which is the body’s natural reaction to stressful and life-threatening situations. The fight-or-flight response, intended to save us from immediate physical danger, can also be experienced when we encounter stress, such as a life change, a toxic relationship, or the challenges of addiction recovery. [fat_widget_right]

Chronic stress and levels of cortisol (the body’s primary stress hormone) that are consistently elevated underlie many physical and mental health issues. Regular practice of yoga, however, has been found to naturally decrease cortisol levels. This natural decrease of cortisol can give the body a chance to return to a state of restful awareness. Restful awareness allows the physical impact of the flight-or-flight response to normalize and gives the body the opportunity to heal.

Treating Trauma

During traumatic experiences, the body may become dysregulated by either over-activation or suppression of the fight-or-flight response. When this occurs, we become overloaded, and the result may be a state of mind that is too anxious, trapped, or some sort of fluctuation between the two. Trauma may be held in the body through heightened or dysregulated physiological states and somatic symptoms. The body itself, then, contains and manifests much of the pain experienced after a traumatic event. As has been said, “The issues live in the tissues.”

When working with individuals who have experienced interpersonal trauma, mental health professionals may find traditional talk therapy alone is not always the most effective course of action.

Trauma and its effects are so often entrenched and complex that a change in a cognitive frame or behavioral pattern ignores a very basic but critical element: the body.

A cognitive symptom of trauma exposure is difficulty or impaired ability to remember, verbalize, and/or process one’s experiences. Therefore, insight-based approaches often are not sufficient on their own. Furthermore, trauma and its effects are so often entrenched and complex that a change in a cognitive frame or behavioral pattern ignores a very basic but critical element: the body.

Techniques working to help increase awareness of internal states and physiological responses to both internal and external stimuli have demonstrated promise in addressing trauma in the body. Reorienting an individual to their body is often a key to unlocking their pain and building a path toward healing.

What Is Trauma-Sensitive Yoga?

An evidence-based practice designed to directly address symptoms associated with traumatic exposure, trauma-sensitive yoga focuses on body awareness in the present moment. Based on the theoretical underpinnings of attachment theory, trauma theory, and neuroscience, TSY helps individuals in treatment recognize choices relating to the body and develop the ability to take effective action based on the knowledge of these choices. The language used in treatment is invitational and emphasizes choice for the person in treatment. The experience is shared, and no physical assists are used.

Unlike traditional yoga, TSY always places emphasis on the internal experience of the individual, not on achieving proper form. The facilitator of the treatment will, while practicing with the individual, help them become accustomed to feeling their body in the present moment, whether by guiding them to feel the way their feet contact the ground or how a particular muscle contracts. Through this guidance, people in treatment can learn what to do about the experience in real time by taking effective action. Everything about the practice is optional, gentle, and designed to help individuals befriend their bodies.

The practice of yoga, with its focus on the mind-body connection, offers both symptom reduction and opportunities for people practicing yoga to heal and grow. Yoga, known to benefit the mind as well as the body, has been proven beneficial for addressing stress, trauma, depression, anxiety, addiction recovery, and even personal growth.

Beyond yoga’s other benefits, research has found individuals who combined TSY with psychotherapy were more likely to experience a decrease in trauma-related symptoms and an increase in positive traits and emotions such as grace, compassion, relating with self and others, acceptance, centeredness, and empowerment.

If you are interested in incorporating yoga into your wellness practices, self-care routine, or mental health treatment but are unsure of where to start, consider bringing it up with your therapist or counselor or primary care physician to see if this approach might benefit you.

References:

1. Buric, I., Farias, M., Jong, J., Mee, C., & Brazil, I. (2017, June 16). Meditation and yoga can ‘reverse’ DNA reactions which cause stress, new study suggests. Frontiers in Immunology. Retrieved from https://medicalxpress.com/news/2017-06-meditation-yoga-reverse-dna-reactions.html
2. Emerson. D., Sharma, R., Chaudhry, S., & Turner, J. (2009). Trauma-sensitive yoga: Principles, practice, and research. International Journal of Yoga Therapy, 19. Retrieved from http://www.traumacenter.org/products/..%5Cproducts%5Cpdf_files%5Cijyt_article_2009.pdf
3. Garfinkel, M. (2006). Yoga as a complementary therapy. Geriatrics and Aging, 9(3). Retrieved from http://www.medscape.com/viewarticle/525187
4. Jackson, K. (2014, November 17). Trauma-sensitive yoga. Social Work Today, 14(6). Retrieved from http://www.socialworktoday.com/archive/111714p8.shtml
5. MacMillan, A. (2017, June 16). Yoga and meditation can change your genes, study says. Time. Retrieved from http://time.com/4822302/yoga-meditation-genes-stress
6. McCall, T. (2008, June 20). Understanding the mind-body connection. Yoga Journal. Retrieved from https://www.yogajournal.com/teach/yoga-therapy-and-the-mind-body-connection-part-1
7. Woodyard, C. (2011). Exploring the therapeutic effects of yoga and its ability to increase quality of life. International Journal of Yoga, 4(2). Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3193654

As a therapist who specializes in treating complex posttraumatic stress, I am often asked whether my practice is “depressing,” or whether it brings me down. It’s an obvious question: Along with the victories and the moments of fulfilling interpersonal connection, I am in vicarious contact with intensely difficult situations and stories. Also, practicing somatic psychotherapy develops one’s sense of empathy: the ability to sense what another person is feeling and to also feel it. So I often literally feel, in my own body, the sensations and emotions of the distress experienced by the people I work with in therapy. This is a good thing, as it is a fairly reliable indicator of what a person in therapy may be experiencing. Fortunately, my training affords me the capacity to feel others’ distress without getting stuck in it.

But no, my practice does not bring me down. I am deeply grateful for my training and my entry into this field. I can’t imagine doing anything else, because I believe increasing humans’ capacity for self-regulation is the most important thing in the world.

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That’s a big statement. I don’t make it lightly.

You might be wondering: why self-regulation, of all things? After all, most people don’t even think about self-regulation or how it relates to our individual or collective lives. The topic doesn’t even cross most people’s minds.

As I noted in a previous article, “The term self-regulation means ‘control [of oneself] by oneself.’ It refers to a system taking the needed steps to keep itself in balance.” Specifically, somatic therapy helps people learn to self-regulate the balance of the fight/flight response in their nervous system. This balance can (and should) change moment by moment, depending on the current situation and environmental demands upon the person. In other words, it’s a dynamic balance—and it has to be accurate or there will be problems!

According to Stephen Porges, we have four basic states (like “gears”) in our autonomic nervous systems. Our thoughts and behaviors at any moment are hugely influenced by the relative proportions of each. These are physiological states in the autonomic nervous system. They are:

1. Social engagement. This state is controlled by the ventral vagal (10th cranial) nerve. In social engagement, a person remains calm. They are truly available to be present with others. They can experience empathy. They are able to hold good boundaries, cooperate with others, and maintain a sense of humor. The key concepts here are calm, flexibility, and empathy. This state is vitally important; it forms the foundation of good self-regulation and, generally speaking, should be the most predominant “gear” in daily life. However, it’s often overlooked, as the public doesn’t tend to have much education about it.
2. Fight. Usually experienced as anger, irritability, or rage, this state is controlled by the sympathetic nervous system (SNS). It comes online when the person’s midbrain structures perceive a threat. The more predominantly the person is in a fight response, the more the prefrontal cortex goes offline and the less the person is able to experience calm or empathy.
3. Flight is usually experienced as fear, anxiety, or restlessness. Also controlled by the SNS, the flight state includes the same loss of cortical function as with fight.
4. And then there is freeze, which is usually experienced as passivity, low energy, amotivation, dullness, foggy-headedness, and reduced capacity for cognition and emotion (other than fear). This state is also mediated by the vagus nerve—but an older, more primitive portion of it, the dorsal vagal system. Basically, freeze is a death preparation state, and it shows up when the body “thinks” social engagement, fight, and flight would be ineffective.

As Peter Levine writes, previous traumatically stressful events that have not been fully resolved in the nervous system will disrupt a person’s self-regulation, biasing their response to present-day events. Specifically, unresolved trauma causes the person to respond with excessive fight, flight, and/or freeze response relative to the current situation.

Self-regulation supports cooperation and healthy group norms. I wish we could wipe out 25% of our fast-food restaurants and liquor stores, replacing each of them with a free somatic therapy clinic.

Here is a thought exercise to illustrate the vital importance of self-regulation and how it impacts just about every situation across our human lives—on small and large scales. Imagine each of the following common scenarios. Then, imagine how each scenario could be different if at least one person involved was able to maintain calm social engagement.

• Bobby is growing up in an impoverished neighborhood. One of his parents is absent and the other is stressed, working two low-wage jobs in order to pay the rent. In his family and in his immediate community, there is no one consistently available who creates a sense of calm and safety. Bobby’s nervous system never learns how to drop out of threat response and into relaxed social engagement. As he grows up, this lack of internal safety and stability has an impact on every interaction and decision he makes.
• On the freeway, one driver doesn’t see another in time and nearly causes a collision—not at all on purpose. The other driver is angry and begins to escalate. The at-fault driver becomes upset by this.
• Two next-door neighbors don’t get along well. One decides to start barbecuing his dinner. The other is allergic to smoke; she yells at him to stop, or else she’s going to get her cousin to beat him up. The first neighbor pulls out a knife and waves it at her.
• A country is faced with a major decision: whether to stop manufacturing a product that has a large negative impact on the environment (including animals and people). Some lobbyists profit majorly from the manufacture and sale of this product. They are competing for economic rankings for their shareholders, so they are focused on increasing financial profit and do not show empathy to those severely affected.
• Two cultures (or one culture and one subculture) have hated each other for generations. The insults and the fighting have gone on for so long that no one remembers the original transgressions. The topic is charged with emotion and exaggeration. Children in each culture are raised to hate (or at least dislike and avoid) the other culture. Eight-year-old Amanda secretly feels curious about the other people and would like to get to know some of them. She doesn’t talk with anyone else about this, because doing so could get her labeled a traitor and ejected from the very family and community she needs in order to survive and grow up. This collectively stuck survival charge isn’t usually in the foreground, but it permeates the background of her daily life.

Each of the above scenarios illustrates the ripple effect of dysregulation and how it lies at the core of most human problems. There are many, many other examples. Imagined the other way—that is, with the influence of a self-regulated person or people—these scenarios can also illustrate the powerful positive impact of self-regulation: it has a strong tendency to stop conflict and exploitation (due to the presence of empathy). Self-regulation supports cooperation and healthy group norms. I wish we could wipe out 25% of our fast-food restaurants and liquor stores, replacing each of them with a free somatic therapy clinic.

And the thing is, we could—if only there were enough aware, self-regulated people to make it happen.

Until then, I’ll hold off on my occasional daydreams of being a barista, or a nature guide in a sustainability program. Instead, my colleagues and I continue to support self-regulation, one nervous system at a time.

References:

1. Porges, S. W. (2001). The polyvagal theory: Phylogenetic substrates of a social nervous system. International Journal of Psychophysiology, 42:123–146.
2. Porges, S. W. (2003). Social engagement and attachment: A phylogenetic perspective. Roots of Mental Illness in Children, Annals of the New York Academy of Sciences 1008:31–47.

Although it remains explicitly absent from the Diagnostic and Statistical Manual of Mental Disorders, complex posttraumatic stress (C-PTSD) is a condition that has gained broad acceptance in the mental health community. The symptoms and features of C-PTSD may be similar to borderline personality and posttraumatic stress (PTSD) and are most commonly associated with experiences of chronic child abuse or neglect, though any uneven power dynamic exploited over a prolonged period—such as kidnapping/hostage situations, indentured servitude, cults, or even intimate partner violence—can be the basis for complex trauma.

Complex trauma’s chief distinction is its prolonged nature. It’s not that your caregiver assaulted you that one time; it’s that your experience as a child was filled with recurring maltreatment, resulting in symptoms that are often diagnosed as attention-deficit hyperactivity (ADHD), depression, and anxiety. While these diagnoses may be accurate, they do not address the origination of the problem.

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How a parent interacts with their child can have a huge impact on the child’s emotional development. If a child is not properly attuned, attended to, or acknowledged as an infant or in early childhood, a lifetime of damage may result. Generally, no visible scars or marks offer clues that anything damaging has occurred. When the person becomes an adult, they may experience serious relationship problems or struggle with addictions and other issues without understanding why. This, too, is complex trauma.

In fact, when someone has been chronically maltreated during any portion of life as a result of any type of abuse or emotional neglect, they may develop an inner propensity to manifest a variety of external symptoms. These tend to include but are not limited to “airheadedness,” anxiety, somatic symptoms (migraines, stomachaches, etc.), dissociation, and depression.

People who experience trauma from an early age must protect themselves in some way in order to cope. One means of protection is to “split off” the part of themselves that is experiencing the trauma. This results in the traumatized person having a fragmented psyche. Fragmentation is really a protective strategy. It serves a person well during traumatic experiences, but tends to be problematic once no longer needed for survival.

This splitting cannot be seen under a microscope or in a brain scan. Rather, it is as if the person develops different, developmentally stunted personas that are frozen in time deep within one’s unconscious memory. Each “persona” or “mode” is rigidly committed to a lack of growth and causes a level of stunted emotional development.

Schemas and Modes

During a child’s upbringing, various inner working models about life are developed. These can result in internalized “schemas.” Schemas develop in all people at an early age; some are adaptive and some are maladaptive. They are comprised of emotions and deeply ingrained beliefs about self, others, and relationships. Schemas are neurologically held as experiential or implicit memories, and are experienced viscerally. For example, one type of schema could leave an internal felt message of, “I know I am not worthy of love; I just know it. I feel it in my being.”

Modes are developed internally in response to schemas and are comprised of the personas created during traumatic or otherwise emotionally dysregulating experiences. Modes are compensatory and are created mainly as protectors. Some protectors are over-compensatory, such as in the case of narcissistic and antisocial personalities. Others are in the form of avoidance, denial, being overly friendly, etc.

Modes are akin to personalities. The necessary personality shows up as needed in response to the trigger at hand.

Everyone operates in modes. Some people with minimal traumatic experiences in childhood have relatively “normal” modes, where triggers aren’t as devastating as in the case of those who come from extremely emotionally deprived childhoods. When particularly strong modes of relating are present, personality conditions may develop.

Dissociative identity (DID) is the clinical term for a person with distinct and separate personas developed as a result of childhood trauma.

Triggers

Triggers usually have a connotation of something negative, but can also occur when a person has been conditioned to experience something positive. For the purposes of this article, I am referring to those triggers that cause a person to maladaptively regress emotionally to an earlier time in life.

Triggering occurs when a person experiences something that reminds them unconsciously of a past traumatic or emotionally upsetting experience. A schema is what is triggered, and a mode is what comes into play to protect the underlying, unbearable emotional pain.

Personas

When threatened by a negative emotional experience, subconsciously a schema is triggered and a mode comes to the rescue to protect the individual from the underlying emotional discomfort. The threatened unbearable emotions may include anger, shame, humiliation, desperation, fear, and emptiness.

Challenging the underlying maladaptive beliefs helps a person who experienced complex trauma begin to assess the damage caused during their childhood. The goal of therapy is integration of the different personas into a cohesive, adaptive, pro-social whole.

For people with personality conditions, a common threat is the potential for warmth, nurturance, or closeness. Such individuals may display personas to stop healthy interpersonal connection from happening.

Why is this? The hope for love may be threatening to a person with a personality condition. The “protector” shows up to stop this threat from becoming a reality. For a person with a personality condition, the hope for attachment may bring up the emotions of vulnerability, neediness, helplessness, powerlessness, and subjugation. These feelings may be too threatening to experience consciously.

If, as a child, a person did not experience consistent nurturance and reassurance when feeling helpless, needy, or vulnerable, but instead experienced abandonment and abuse, then dissociation and over-compensatory measures may have been created. Over-compensatory measures may occur in the form of another personality, such as The Entitled, The Superior One, The Rager, or The Detached Observer. These modes are protective.

Think of the concept of a person having part of their personality stuck in an early developmental stage, such as age 3. Now, think of a person with narcissism having a “rage attack.” The image you conjure may resemble the temper tantrum of a 3-year-old.

This is an example of a trigger leading to an emotional regression. The rage attack is akin to the “protection” for the person. While it may be maladaptive, it is effective in protecting the person from feelings of vulnerability and helplessness.

Treating Complex Trauma

One of the most helpful first steps in treating complex trauma is to identify the various modes within a person’s psyche. Some people have a few distinct personas, such as the ones mentioned above. Others include personas with attributes fitting titles such as The Rebel, The Fighter, The Victim, The Seducer, The Liar, The Party Girl, and so on. These labels are self-descriptive; the corresponding personas may show up when particular schemas are triggered as a result of threats being sensed in the environment.

Some of these personas act “normal” and can be masterful at concealing dysfunction. Protective in nature, these modes are usually the ones that present to the world and can be likened to a mask. For healing to occur, it is helpful to identify all modes—the “normal” ones as well as the socially maladaptive ones.

A good therapist can help a person struggling with complex trauma identify their schemas, modes, triggers, and personas, and can help the person learn to integrate these parts into a cohesive whole. Keep in mind it is not the goal of therapy to eliminate a person’s protectors, but to embrace them and incorporate them into the person’s sense of oneness.

Integration succeeds differentiation. Once the different parts are identified, the therapist can help the person ascertain the primary underlying threatening schemas residing in their psyche. Once these underlying schemas are pinpointed, the triggers make sense. Challenging the underlying maladaptive beliefs helps a person who experienced complex trauma begin to assess the damage caused during their childhood. The goal of therapy is integration of the different personas into a cohesive, adaptive, pro-social whole.