Side view of person with shoulder-length hair looking to the side out window of trainCancer is a life-changing and potentially life-threatening diagnosis. Before the news can even sink in, you buckle in for your wellness team’s treatment recommendations, which may include chemotherapy, radiation, and/or surgery. The “warrior mentality” kicks in as an unexpected fight against your own body begins in earnest.

During the active treatment phase, you are surrounded by medical professionals and, if you’re lucky, family and friends supporting you through the various treatments. Then, suddenly, hopefully, you cross that finish line and are told there is no evidence of disease (NED). Cheers and celebrations ensue. NED! It’s all over. You’re a cancer survivor and you get to return to your life.

That’s the way it’s supposed to work, yes?

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Unfortunately, cancer survivorship can bring an emotional tsunami of its own. Many survivors find themselves dealing with the chemotherapy effects of fatigue and concentration problems, which may impact their ability to function at work or at home. Additionally, there is the emotional aftermath of coping with a life-threatening diagnosis and life interruption; possible body image issues resulting from surgery (e.g., mastectomy); perhaps major changes in narrative (e.g., having children, financial strain); changes in self-esteem; survivor’s guilt (“Why did I survive while others didn’t?”); fears of recurrence; and a foreboding sense of a shortened future, to name a few concerns.

It is common to experience emotional turbulence post-cancer. There is nothing wrong with you for not being able to just resume your life after treatment. It may take some time to emotionally heal. Survivors may experience depression, anxiety, even posttraumatic stress. Indeed, PTSD symptoms are not reserved for combat veterans. Survivors of cancer have endured a battle as well—it just looked different.

Cancer survivors can experience myriad symptoms such as being triggered into a state of high anxiety by certain smells, sights, or bodily feelings. They may discover they can’t free their minds from intrusive and unsettling thoughts, memories, or images of their cancer care.

Cancer survivors can experience myriad symptoms such as being triggered into a state of high anxiety by certain smells, sights, or bodily feelings. They may discover they can’t free their minds from intrusive and unsettling thoughts, memories, or images of their cancer care. There may also be a strong desire to avoid certain people or situations because they might be anxiety-provoking.

A survivor may oscillate between feeling too much and feeling numb. It’s also not uncommon to experience body pain or to immediately jump to thinking the cancer is back. Some may find themselves struggling to move forward, afraid to dream of a future again. These types of symptoms are a reminder you have survived a life-altering event. It’s okay to allow yourself some time to heal the post-cancer emotional wounds.

To monitor your emotional health after cancer diagnosis and treatment, it may be helpful to remember the word “tsunami.” TSUNAMI may be used as a mnemonic to help you assess whether you are dealing with posttraumatic stress symptoms. As many cancer survivors would attest, the word fits very well to describe the turmoil that can occur in the aftermath of cancer.

What You Can Do to Help Yourself

If some of the above questions resonate with you, there is a lot you can do to promote emotional healing. First, seeking counseling from a mental health professional with training in health psychology may help quell your symptoms. Another goal with therapy is to help you feel like you are not just surviving life but thriving again.

There are many other treatment methods that may be used to promote healing. Some methods that are used to help people with posttraumatic stress, such as trauma-focused cognitive behavioral therapy, are utilized to help survivors of cancer. This treatment orientation provides psychoeducation about trauma, fosters development of relaxation tools, and teaches methods for examining dysfunctional thought patterns and desensitizing triggers. Other avenues survivors might explore are cancer support groups, acupuncture to relieve anxiety, iRest meditation, and yoga.

The key to thriving after cancer is to intervene early and thoroughly. So no matter what phase of your cancer journey you are in, it is important to monitor your mood. If you are emotionally struggling, reach out to a mental health professional to provide guidance through your recovery and beyond NED!

Young child sits in lap of parent with short hair who reads large picture book. Both parent and child are smiling“As courage imperils life, fear protects it.” —Leonardo da Vinci

Da Vinci’s sentiment might not sound helpful to you. It doesn’t to me. In my view, courage expands life and fear shrinks it. But this isn’t how everyone sees it. At some point in their lives, about 25 million Americans (roughly 4 million more than the population of Florida) will experience posttraumatic stress (PTSD), and for them, fear may feel like a reasonable and necessary part of everyday life.

Posttraumatic stress can occur after exposure to an upsetting or frightening event such as actual or threatened death, serious injury, sexual violence, or a prolonged distressing experience. The emotional, behavioral, and psychological effects of posttraumatic stress can include depression, anxiety, sleep problems, and suicidality. Because of the debilitating impact of posttraumatic stress, some people are unable to work or engage in productive lives. Friendships and physical health can also suffer.

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Posttraumatic symptoms can include the following:

People respond in different ways to these symptoms, and some recover more quickly than others. Effective coping methods are predictive of better outcomes. One method of coping is known as acceptance and commitment therapy (ACT).

Acceptance and commitment therapy involves taking action toward values with an acceptance of increased emotional and sometimes physical pain. ACT methods help improve mindful awareness of the present moment and of emotional pain, distorted thinking, and physiological distress. The six ACT domains include the following:

Present Moment

Posttraumatic stress symptoms can lead to excessive worry about the future or regret or sadness about the past. When we are caught in the past, we can get stuck on what is gone or unfixable. When focused on the fortune telling of the future, we can get stuck jumping to conclusions. Through engagement of one’s senses into the here and now, mindful awareness of the present moment helps mitigate these cognitive distortions.

Try it. Take a moment to feel your feet in your shoes or your clothes on your body. Notice the space between where the cloth meets the skin and focus in. Try to really feel your way through the moment. When you shifted focus, you may have experienced a softening of your thoughts.

Breath is also an important part of present-moment awareness. PTSD symptoms often involve an increased alertness and fight-or-flight responses. Using controlled and relaxed breathing techniques, the startle symptoms can be decreased and even stopped.

Identification of Values

One of the challenges of posttraumatic stress is the decreased connection with meaning. The emotional and physical hurt that results from the trauma can feel meaningless, and individuals dealing with PTSD often report the pain as pointless and cruel.

It is not uncommon to feel disconnected from one’s values following traumatic events. When we lose touch with the importance of our lives, including our role as parent, employee, or partner, we lose reason to push on. Viktor Frankl, in his seminal work Man’s Search for Meaning, put it best: “The man who knows the why of his life can bear any how.” Our “why” is defined through an examination of our values. Soldiers returning from combat may benefit from remembering they value being a teacher to their children. Teachers who fear returning to work could experience greater confidence if connected to the value of being a leader in their profession.

Commitment to Action

Values are maintained not in the mind, gut, or heart, but through action. A value is best felt through verbs and events. When a person is engaged in the event, it is sufficient to say they are living in their values. Value for physical health is evident in consistent attendance at the local gym. Value for music is witnessed not through a dream of becoming a famous musician, but through daily commitment to practicing on the piano.

When a person is dealing with posttraumatic stress, it is important to commit to actions to help them move toward their value. If a father finds it hard to appreciate his family because he can’t stop thinking about combat, he must put his energy into events that foster familial closeness, such as spending time with his children and taking his partner to dinner. After all, before the trauma, these were the events that gave life meaning and purpose.

Self-Observation

One of the hardest parts of dealing with posttraumatic stress is the constant bombardment of physical and emotional stress. The body is in a persistent state of alert, which can take a toll. For this reason, many individuals dealing with PTSD feel they are “broken” or “weak.” They may feel guilty about their inability to “beat” the symptoms.

An important skill in managing PTSD symptoms involves recognizing the mind and body are not you.

An important skill in managing PTSD symptoms involves recognizing the mind and body are not you. When we are able to step away from our cognitive and physical experiences, we become more compassionate and open to ourselves.

If our body is setting off alarms due to fears of bombs, death, or whatever, we would benefit from mentally looking at the body and noticing its sensations without judgment, because our experiences—both internal and external—do not have to be defined, only felt. This is not an easy process, but for the person dealing with posttraumatic stress, observing the self with curiosity and openness is an important step toward recovery.

Cognitive Defusion

Anyone who has gone through a frightening moment knows what inner turmoil feels like. It is hard to stop thinking about the stressful event. We replay the event in our head over and over again. The lover’s betrayal, the results of an important physical exam, or a lost puppy can all cause us to obsess. So what do we do?

Instead of trying to avoid the thought or find a better one, allow the thought to exist without taking ownership of it. Posttraumatic stress and negative thinking go hand-in-hand. If the mother is to reengage with her family or the police officer is to go back to work, they will likely have to do so with negative thoughts in their heads. By defusing from thoughts, we do two things. First, we disconnect from their truth. And second, we take away their power.

Acceptance

As light comes from heat and heat from pressure and friction, so does growth come from pain. Posttraumatic stress requires that the person exposes themselves to the unwanted distress. By facing fear, we allow our mind to create new, healthier symbols and definitions of what the fear represents. For this reason, we need to be willing to feel distress when moving toward our values.

Posttraumatic stress is a challenging condition to overcome. But like anything in life, it can and is overcome daily by people just like you and me. It starts with believing in yourself and remembering there is nothing wrong with being human. The part of us all that overcomes challenges is available to us every day. Humans are wonderfully adaptable. So take these skills and if you need them or someone you know could benefit from them, share them. The life we live is here and now, and if we trust movement and commit to what is important, then the valued future we seek is just a moment away.

If you want support in healing from posttraumatic stress, contact a licensed therapist who is trained in acceptance and commitment therapy.

References:

  1. American Psychiatric Association. (2013). Diagnostic and statisticalmanual of mental disorders (5th ed., text rev.). Washington, DC: Author.
  2. Frankl, V. (1984). Man’s search for meaning: An introduction to logotherapy. New York: Simon & Schuster.
  3. Hayes, S., & Strosahl, K. (2004). A practical guide to acceptance and commitment therapy. New York, NY: Springer.

Photo shows rear view of two people with long hair wearing coats sitting on back of bench by waterJune is recognized as National PTSD Awareness Month. One of the populations most at risk for developing posttraumatic stress are survivors of sexual assault. In fact, sexual assault is the event that most commonly causes posttraumatic stress among women, with 94% reporting symptoms during the first 14 days (Riggs, Murdock, & Walsh, 1992). Additionally, 30% of sexual assault survivors continue to experience PTSD symptoms nine months later (Rothbaum & Foa, 1992). According to the National Crime Victimization Survey (2007), a woman is sexually assaulted somewhere in the United States every 120 seconds.

Sadly, sexual violence is still shrouded in a cloak of silence due to the stigma many people associate with rape. In spite of this, research has identified that 92% of survivors disclose what happened to at least one person close to them, such as a family member, significant other, or trusted friend. Unfortunately, these disclosures are not always met with support. In fact, anywhere from 25% to 75% of survivors who share information about their traumatic event experience a negative or non-supportive response from at least one person in their personal support system (Campbell, Ahrens, Wasco, Sefl, & Barnes, 2001; Golding, et al., 1989; Filipas & Ullman, 2001).

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These numbers alarmingly attest to why survivors often suffer in silence. If they confide in someone, they risk being blamed, judged, or worse, not believed. These kinds of negative responses may be further traumatizing and drive survivors back into a world of secrecy where healing is delayed or even thwarted.

The time is now to create a culture where survivors of sexual assault can feel confident and safe in sharing their experiences. Survivors should be able to find respite in sharing their trauma while having it be received with support, warmth, and respect. PTSD Awareness Month can be a campaign for change. Let us lift up survivors with words of support and validation. At the same time, let us cease to accept rape myths that perpetuate and contribute to negative responses upon disclosure.

The time is now to create a culture where survivors of sexual assault can feel confident and safe in sharing their experiences.

Additionally, this paradigm shift where survivors are unequivocally supported allows all to play a critical part in attenuating PTSD symptoms. When survivors disclose their trauma and they experience a positive social response, this promotes healing, faster recovery, and fewer PTSD symptoms (Ullman & Peter-Hagene, 2014).

Here are some powerful ways to stand by a survivor and support them when they break through their silence. Remember the acronym BRAVE—which is easy, as it embodies every survivor of sexual trauma. BRAVE serves a communication model to be used as guidance for signaling five types of positive responses that help promote healing for survivors of sexual violence.

Conclusion

With the BRAVE communication model, when a survivor of sexual violence shatters the silence by sharing, you can be ready to respond with kindness, compassion, and the gentle care survivors deserve. Your response may be an integral part of their healing process.

References:

  1. Campbell R., Ahrens C., Wasco S., Sefl T., & Barnes, H. (2001). Social reactions to rape victims: Healing and hurtful effects on psychological and physical health outcomes. Violence and Victims, 16(3), 287-302.
  2. Filipas, H. H., & Ullman, S. E. (2001). Social reactions to sexual assault victims from various support sources. Violence and Victims, 16(6), 673-692.
  3. Golding, J. M, Siegel, J. M., Sorenson, S. B., Burnam, M. A., & Stein, J. A. (1989). Social support sources following sexual assault. Journal of Community Psychology, 17(1), 92-107.
  4. Rothbaum, B. O., & Foa, E. B. (1992). Subtypes of posttraumatic stress disorder and duration of symptoms. In J. R. T. Davidson & E. B. Foa (Eds.) Posttraumatic Stress Disorder: DSM-IV and Beyond. Washington, DC: American Psychiatric Press.
  5. Rothbaum, B. O., Foa, E. B., Riggs, D. S., Murdock, T., & Walsh, W. (1992). Prospective examination of post-traumatic stress disorder in rape victims. Journal of Traumatic Stress, 5(3), 455-475.
  6. Ullman, S. E., & Peter-Hagene, L. (2014). Social reactions to sexual assault disclosure, coping, perceived control. Journal of Community Psychology, 42(4): 495-508. doi: 10.1002/jcop.21624
  7. National crime victimization survey. (2007). U.S. Department of Justice. Retrieved from https://www.bjs.gov/index.cfm?ty=dcdetail&iid=245

Shot of a young woman drinking a cup of coffee while looking out of a window“Memory is not a recording of an ‘image’ or a ‘trace’ but part of the process of knowing and understanding.” —Rosenfield, 1992; p.18

There are polarizing beliefs when it comes to eye movement desensitization and reprocessing (EMDR) therapy. On one end, it is viewed as a+ cure-all treatment for mental health symptoms. On the other, critics see it as a treatment akin to modern-day snake oil.

The protocol for EMDR therapy is comprehensive and detailed. Put simply, the idea is to transform disturbing input—process and decondition it—into an adaptive resolution and a psychologically healthy integration. The model is past-focused, meaning one is going back in time to recall events as opposed to addressing current life stressors (not that the two are mutually exclusive). This includes redefining the event, finding meaning in it, and alleviating self-blame while integrating new skills (Shapiro, 2001). The modality focuses on the core cognitions or self-referential beliefs individuals associate with the disturbing events. These often fall into domains related to personal responsibility, safety, and power or control. “Trauma in each of these domains is reflected by the client’s distorted self-referencing beliefs linked to the effects of unresolved memories” (Nickerson, 2017).

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EMDR is an evidence-based therapy primarily used to treat posttraumatic stress (PTSD), but as it gains momentum in mental health circles, indications for its use are ever-expanding. The question for me is less about EMDR efficacy or benefit. The concern is the theory behind it and my general curiosity regarding its unique properties. There are aspects of the treatment that are altogether strange. Likewise, it contains components that are familiar to popular understanding of memory and a few things that tend to go overlooked or are forgotten.

Strange

EMDR was founded by Francine Shapiro in 1989. The legend is she was walking in a park and thinking about something distressing to her. She noticed that moving her eyes from tear duct and back to her periphery (i.e., side to side) lessened her distress. This was the early evolution of utilizing what is called bilateral stimulation. During the processing stage of EMDR therapy, the practitioner will use their fingers, tactile sensors, and/or auditory sounds that activate from left to right or vice versa. The theory is this process stimulates each hemisphere of the brain. The left hemisphere is primarily focused on language, linguistics, and narratives of our experience as opposed to the experiential aspect of the right hemisphere. In this manner, the person processing the traumatic memory integrates both the story and the felt experience. The bilateral stimulation is said to parallel how memory is consolidated during dream or REM (rapid eye movement) states when we sleep.

Fundamentally speaking, accelerated processing during EMDR splits the attention of the individual. During bilateral stimulation (i.e., finger movements, tones in the ear, or hand sensors), working memory is taxed because one must partially focus on the stimulation. This multitasking softens the emotional blow of recalling disturbing memories.

For those unfamiliar to the processing aspect of EMDR, practitioners are trained to sit close to the person in treatment. During this process, the therapist and person in therapy are cohabiting each other’s personal space, with one knee a couple of inches from the other’s. The direction is for the two people to be seated in an orientation “like two ships crossing in the night.” This unique approach to treatment creates an added level of intimacy and implicit vulnerability. It is strange and often overlooked when considering how the intervention benefits people in therapy. In a garden-variety individual therapy session, the two people are often sitting across the room from each other or at least several feet away.

Another oddity of EMDR is the historical context and initial hypothesis pertaining to trauma. In 1989, Shapiro questioned if trauma was essentially a disruption in the excitatory and inhibitory balance of the brain. This was two years after Prozac was introduced to the United States and a year before the Decade of the Brain. Mental health was beginning to be understood from a chemical or biological perspective. EMDR benefited from hitching the idiosyncratic trauma treatment to the biological wagon of mental health. EMDR’s individualized treatment would offer a correction to this brain imbalance akin to the overly simplistic solution for depression being a deficit of serotonin.

Familiar

Popular understanding of memory is that it is solely a brain function, with stored archives of our moments from the past organized in little synaptic shelves of neurons. This concept of memory as photographic snapshots stored in an album of existence is analogous to social and news media feeds displaying a history of ourselves across set positions on timelines. The click or swipe reveals the exact same image with no distortion. In Israel Rosenfield’s book The Strange, Familiar, and Forgotten: An Anatomy of Consciousness, he notes our false conception of memory based on Freudian ideas of the unconscious: “The problem is that we have tended to think of memories as unconscious items that one brings to consciousness, not as part of consciousness” (1992; p. 12). The false dichotomy of consciousness versus unconsciousness holds this misconception in place.

In Pixar’s animated film Inside Out, the main character’s memory process was portrayed in a similar manner. Her brain would produce marble-like spheres that rolled down a mechanical carousel to produce videos of previous experiences. The film portrays an exact reconstruction of past events as if these histories could be called upon via a brigade of emotional activity. This is not unlike the theory behind EMDR therapy. Disturbed memory channels in the limbic system are said to be clogging or inhibiting the individual from moving past the traumatic event. A subtle distinction is important to note: each time one thinks of a memory, they are essentially reconstructing or imagining what happened. This process creates tiny errors similar to the manner in which one copies a computer file. Over time, these little distortions add up and the factual elements of the memory are changed. The most salient and accurate memories are the ones we only rarely recall (like the original file before it is copied). The misconception of memory processes fits with Western culture’s ego-centric, fixed sense of self; “the conviction that memory is one thing is an illusion” (Eagleman, 2011; p.126).

The idea of having storage units or filing cabinets in the brain holding our past experiences aligns with current cultural frameworks (i.e., email, cloud technology, digital folders) and therapeutic modalities related to trauma and clogged memory channels (i.e., EMDR therapy). Rosenfield (1992) is explicit in drawing attention to this faulty neurology. When one remembers, they are referring to an event/object/person as they are represented based on one’s own subjective experience, “not mechanical reproduction” (p.42). Memory is less of a product of history or biological remnant, but a dynamic ability to integrate knowledge in a relational manner. The timestamp or notarizing of the event occurs within a conceptualization of who it is we think we are as a person.

Memory is rooted in our sense of time and part of the very structure of conscious knowledge. It is not an isolated phenomenon, but rather a manifestation of subjective states created by brain activities (Rosenfield, 1992). Therefore, failure of memory is not due to the loss of specific items “stored” somewhere in the brain, but rather a breakdown of the mechanisms of consciousness; “there are no memories without a sense of self.” As Rosenfield (1992) notes, “Without knowledge of one’s own being, one can have no recollections. How can I remember my parents, my house, if I am not sure I exist?” (p.41).

Forgotten

You need to remember EMDR therapy is an intervention that implies a Western understanding of the self or mind. It turns out the way highly educated, wealthy, democratic minds think is not representative of the entire globe. Most of us in the West do not think of ourselves as a body; we think we “have” a body. There is a notion we are the chariot drivers of our experience or, put another way, there is this little person inside our heads that has all types of likes and dislikes, proclivities, and things we retract from or avoid. This is an ego-centric perspective of the mind.

If you stop and pay attention to the present moment, one’s habitual patterns of cognition start to become clearer. The ego-dominating belief of our existence lying somewhere in the center of our skulls begins to be challenged. This is worth remembering.

By comparison, if you ask a Sri Lankan about themselves, they may describe their interpersonal relationships, family, and roles or responsibilities. This is a socio-centric version of the self with less of a demand on individuality. Watters (2010) articulates this distinction via several cultural specific examples in his book, Crazy Like Us: The Globalization of the American Psyche. He describes the 2004 Indian Ocean tsunami that killed around a quarter million people. Sri Lanka was one of the areas hit especially hard by this tragedy.

Western mental health practitioners rushed into these areas without knowledge of the culture. They did not know how to speak the language or have any awareness of local conceptualizations of trauma. This included benevolent EMDR therapists who assumed there would be an epidemic of PTSD. However, if you asked the Sri Lankans where their trauma resided, they generally did not point to their heads or speak of their minds being broken. For them, the damage was to the community and broken relationships. “Because Western conception of PTSD assumes the problem, the breakage, is primarily in the mind of the individual, it largely overlooks the most salient symptoms for a Sri Lankan, those that exist not in the psychological but in the social realm” (Watters, 2010; p.92).

The Westernized perspective is assumed to be a universal one. When one considers trauma, they must consider the time it happens and the cultural frame it occurs in. The consequence of an ignorant global construct for trauma is we remove the nuanced experience from other cultural narratives and beliefs that might give meaning to how the person suffers (Watters, 2010).

Self-Centered Awareness

David Foster Wallace (2005) hit on the margins of this notion—self-centered awareness—in his commencement address to Kenyon College titled This Is Water. He spoke about the choice of where we place our attention within conscious awareness (as opposed to relying on our “default setting” or autopilot) and how one can cultivate compassion within the banal aspects of daily life:

And the so-called real world will not discourage you from operating on your default settings, because the so-called real world of men and money and power hums merrily along in a pool of fear and anger and frustration and craving and worship of self. Our own present culture has harnessed these forces in ways that have yielded extraordinary wealth and comfort and personal freedom. The freedom to be lords of our tiny skull-sized kingdoms, alone at the center of all creation.

There is an ancient technology available to emancipate us from the constraints of these small, isolative worlds. To notice this ostensible imprisonment, all one need do is sit down in silence and observe where their mind goes. Who is producing this stimulation and is there a navigator of control? What happens when all you do is focus on the inhalation and exhalation of the breath?

Mindfulness and meditation practices will not cure individuals from the impacts of trauma or reoccurring disturbing memories. However, it is a prophylactic to inhibit self-centeredness or personalization of momentary experience (which tends to lead to the anxiety-provoking reoccurrences of mind).

When one has a thought, feeling, or sensation, it is often turned into a belief that becomes self-referential. A simple interaction with a partner or family member illuminates this silly human deficiency. If the person yawns during a conversation (the thought), this can lead to a belief (e.g., the person is bored) which is then internalized (i.e., “I am unlikable” or “unlovable.”). One falls down this self-deprecating rabbit hole all too quickly. The antidote is to just notice what is arising in terms of thoughts and beliefs before assuming a story about yourself.

If you stop and pay attention to the present moment, one’s habitual patterns of cognition start to become clearer. The ego-dominating belief of our existence lying somewhere in the center of our skulls begins to be challenged. This is worth remembering.

References:

  1. Eagleman, D. (2011). Incognito: The secret lives of brains (1st American edition). New York: Pantheon Books.
  2. Rosenfield, I. (1992). The strange, familiar, and forgotten: An anatomy of consciousness. New York: Knopf.
  3. Shapiro, F. (2001). Eye movement desensitization and reprocessing: Basic principles, protocols, and procedures (2nd edition). New York: Guilford Press.
  4. Wallace, D.F. (2005). This is water. Transcript retrieved from https://web.ics.purdue.edu/~drkelly/DFWKenyonAddress2005.pdf
  5. Watters, E. (2010). Crazy like us: The globalization of the American psyche. New York: Free Press.

Side shot of person with short hair and beard clasping hands behind head looking seriousAlthough posttraumatic stress (PTSD) tends to be the issue that most often comes to mind when we consider trauma, there are a number of other responses, including depression, anxiety, substance abuse, and difficulties in relationships. Most of these other issues are embedded within the constellation of PTSD and will make more sense as we understand the condition. Many people think of combat veterans when they think of PTSD. Indeed, much of what we know about trauma its effects is a result of the experiences of Vietnam veterans. While trauma responses of course existed prior to the Vietnam war, there had not been a whole lot of focus on understanding traumatic reactions (Herman, 1992).

Many different types of events can be traumatic. Trauma responses can follow any major change or disruption in a person’s life. Some examples that may come to mind include a serious and potentially life-threatening accident, assault, natural disaster, or combat. Other experiences can be traumatic as well, including surviving or witnessing a crime; physical, verbal, emotional, or sexual abuse; bullying; or even a big relocation.

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In the time immediately following a trauma, many people have experiences of PTSD. In some cases, those experiences decrease over time and the person naturally recovers. It can be helpful to think of PTSD as a process where something got in the way of that natural process of recovery. A therapist works to determine what has interfered with routine recovery. In each trauma experience, the factors that can influence the responses vary. As a result, there are as many individual examples of things that can block a smooth recovery as there are individuals with PTSD (Resick, et al., 2008).

However, there are commonalities among PTSD experiences. Several categories of experiences tend to follow a traumatic event. In particular, the experiences of PTSD fall into four clusters (APA, 2013).

The first cluster is the reexperiencing (intrusion) of the event in some way. This may include nightmares about the event or other scary dreams, flashbacks (acting or feeling as if the incident is recurring), and intrusive memories that suddenly pop into mind. Individuals might have intrusive memories when there is something in the environment to remind them of the traumatic event (including anniversaries of the event) or even when there are no reminders. Common times to have these memories are before falling asleep, when relaxing, or when bored.

Therapeutic work serves to not only provide relief from this cycle, but to eradicate the interruption in the recovery process.

A second set of experiences concern arousal, which refers to a constant alarm signal. As might be expected, when reminded of the event, a person with PTSD is likely to experience strong emotions. Accompanying these feelings are physical reactions similar to the ones we might experience coming face to face with a saber-toothed tiger. Indicators of arousal experiences include problems falling or staying asleep, irritability or outbursts of anger, difficulty concentrating, startle reactions such as jumping at noises, or always feeling on guard or looking over our shoulder even in the absence of an external reason.

The third cluster of trauma experiences is avoidance of reminders of the event. Although it is important to point out this avoidance is often not deliberate, a natural reaction to intrusive memories and strong emotional reactions is the urge to push these thoughts and feelings away. We might avoid places or people who remind us of the event. Some people avoid watching certain television programs or turn off the TV altogether. Some people avoid reading the newspaper or watching the news. We might avoid thinking about the event and letting ourselves fully experience our feelings about it. There might be certain sights, sounds, or smells we find ourselves avoiding or escaping from because they remind us of the event.

Sometimes people with PTSD have trouble remembering all or part of the event. Other times, people with PTSD feel numb and cut off from the world around them. This feeling of detachment or numbness is another form of avoidance. Sometimes it is described as feeling as though the person is watching life from behind glass.

Someone navigating things like reexperiencing, hyperarousal, and avoidance may begin to develop reconstructed beliefs about their life, the world, others, and themselves. It makes sense this set of experiences on a day-to-day basis might begin to reshape our view of not only ourselves and others, but about the world how it works. This refers to the fourth cluster of PTSD, the negative cognitive (or mood-based) shifts that can occur following traumatic experiences.

Conclusion

With this overview of trauma and how the PTSD cycle tends to maintain itself, we can begin to better understand how traumatic events can lead to the types of trauma reactions and PTSD experiences we often see (Resick, et al., 2008). Each of these four components contributes to the others in a cyclical way that interrupts the natural recovery process following a traumatic event. Therapeutic work serves to not only provide relief from this cycle, but to eradicate the interruption in the recovery process.

If you would like help in recovering from trauma (or your responses to it), contact a therapist who specializes in posttraumatic stress-related issues.

References:

  1. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th, text rev.). Washington, DC: Author.
  2. Herman, J. L. (1992). Trauma and recovery. New York: Basic Books.
  3. Resick, P.A., Monson, C.M., & Chard, K.M. (2008). Cognitive processing therapy: Veteran/military version. Washington, DC: U.S. Department of Veterans Affairs.

Two people stand in garden and do tai chiA racing heart and a roiling stomach. Panic attacks, nightmares, or fatigue. The body has myriad ways to manifest the many faces of trauma and fear. And for many people, getting help to cope with the symptoms of emotional distress means going through “talk therapy”—a kind of psychotherapy based on verbally processing thoughts, feelings, and experiences.

Now, though, the rapidly growing field of somatic psychotherapy is shifting the paradigm from talking to feeling—and this approach is offering new promise for healing trauma through body-centered techniques, such as Somatic Experiencing.

Somatic Psychotherapy Is Body-Centered Psychotherapy

Somatic psychotherapy—also called body psychotherapy—focuses on the complex and profoundly powerful connections between body and mind and how those connections affect how we process and recover from trauma and other emotional distress. Somatic psychotherapy arises from the premise that, along with thinking about the world and how to respond to it, humans engage with others and the world through sensations, movement, and expression.

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In response to situations and stimuli of all kinds, the body’s core response network, or CRN, is activated. This network, which is made up of the autonomic nervous system, the limbic system, and other regulatory functions, is responsible for organizing and generating an immediate response to challenges presented by a person’s environment, such as the well-known “fight, flight, or freeze” response to stressors and perceived dangers.

In that kind of situation, the CRN signals the body to release a flood of stimulant chemicals, such as adrenaline and cortisol, creating a surge of energy that throws the system temporarily out of balance.

When animals are faced with threats—say, from predators—they experience those responses too. But once the threat has passed, they typically discharge that “survival” energy with movements such as shaking, sighing, or stretching before returning to normal behavior. For them, that kind of event is generally experienced as an isolated incident and causes no lingering symptoms.

But for humans, returning to “normal” after a traumatic experience is not so simple. People who experience sudden or ongoing trauma or other kinds of distressing events typically don’t have ways to clear their systems of the survival, or arousal, energy produced in response to those situations. That energy lingers in the body, and if unresolved, may result in conditions including posttraumatic stress (PTSD), depression, phobias, muscle aches and pains, irritable bowel syndrome and other digestive issues, insomnia, and autoimmune disorders.

Somatic Therapy Is Not “Talk Therapy”

The goal of psychotherapy is to help people resolve issues that trigger emotional and physical distress. With approaches such as cognitive behavioral therapy, people seeking help are encouraged to talk about their experiences in order to gain insights into patterns of negative thinking, identify harmful behavior patterns, or learn new ways to cope with triggers for stress. This kind of “talk therapy” might also include activities such as journaling, poetry, and other kinds of writing, and even art and drama therapy.

But these approaches place heavy emphasis on cognitive functioning and verbal expression—and while a person in this kind of therapy might talk about physical symptoms of trauma or distress, engaging the responses of the body itself might play a fairly limited role in the therapeutic process.

Somatic Experiencing Brings Completion

Somatic psychotherapy begins with the body, working to discover how and where trauma is being physically experienced—and finding ways to safely “discharge” the energy related to that trauma.

Somatic psychotherapy begins with the body, working to discover how and where trauma is being physically experienced—and finding ways to safely “discharge” the energy related to that trauma.

While traditional “talk therapy” encourages people to think about traumatic experiences and express their feelings in words, the somatic approach focuses instead on fully feeling the body’s sensations and the emotions that accompany them. People are encouraged to engage with the body’s responses to memories, experiences, and surroundings. Somatic Experiencing, created by Dr. Peter Levine, is one somatic psychotherapy modality.

In recent work published in Frontiers in Psychology, Levine, in collaboration with Somatic Experiencing practitioners Peter Payne and Mardi A. Crane-Godreau, reviews the broad range of applications for this approach and its potential for supporting recovery from trauma caused by combat, earthquakes, and other natural disasters.

Somatic Experiencing employs three core strategies for resolving trauma-related energies:

Mindful Movement Supports Somatic Therapy

Somatic psychotherapy often incorporates movement to help regulate the autonomic nervous system and bring about a state of “biological completion” in which trapped arousal energy has been resolved and the system is restored to balance. Breathwork and “moving meditations,” such as qigong, yoga, and tai chi, can help to engage the vagus nerve and ease bodily symptoms of trauma, such as muscle pain and headache.

Somatic psychology draws from ancient mind-body practices as well as ongoing research in psychology, biology, and the neurosciences. With the support of new insights into the intimate and profoundly powerful connections between the body and brain, the field of somatic psychotherapy continues to grow, creating more opportunities to help the body heal itself from trauma—one step at a time.

June is National PTSD Awareness Month. For help with trauma and related issues, contact a therapist in your area.

References:

  1. Barratt, B. B. (2013, January 10). The emergence of somatic psychology and bodymind therapy. London: Palgrave McMillan.
  2. Gold, P. (2014, November 1). Somatic psychology: The complementary nature of qigong and counseling. Retrieved from http://www.portlandtherapycenter.com/blog/somatic-psychotherapy-the-complementary-nature-of-qigong-and-counseling
  3. Ogden, P., Pain, C., Kekuni, M., & Fisher, J. Including the body in mainstream psychotherapy for traumatized individuals. Retrieved from https://www.sensorimotorpsychotherapy.org/article%20APA.html
  4. Payne, P., Levine, P. A., & Crane-Godreau, M. A. (2015, February 4). Somatic experiencing: Using interoception and proprioception as core elements of trauma therapy. Frontiers in Psychology. Retrieved from http://journal.frontiersin.org/article/10.3389/fpsyg.2015.00093/full
  5. Payne, P., Levine, P. A., & Crane-Godreau, M. A. (2015, April 14). Corrigendum: Somatic experiencing: Using interoception and proprioception as core elements of trauma therapy. Frontiers in Psychology. Retrieved from http://journal.frontiersin.org/article/10.3389/fpsyg.2015.00423/full
  6. Somatic Psychology – Body Psychology. Retrieved from http://usabp.org/somatic-psychology-body-psychotherapy/
  7. What Is Somatic Psychotherapy? Retrieved from https://www.ciis.edu/academics/graduate-programs/somatic-psychology

Black-and-white photo of person sitting in window with glass and bottle of wine, hand pressed to headDid you know one of the main predictors for having a substance use disorder is experiencing trauma?

A quick internet search yields many definitions of trauma. I think the simplest definition is this: an emotional response to a terrible event.

Note I did not specify what type of event or what type of response. These are all individualized. What might be traumatic for me could have little or no impact on you. A person experiencing trauma is in the best position to define their experience based on what they are thinking, feeling, and going through.

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In one survey of adolescents receiving treatment for substance use, more than 70% had a history of trauma exposure. Teens who experienced physical or sexual abuse were three times as likely to use substances than those who had not. And 59% of young people with posttraumatic stress (PTSD) develop substance use disorders.

Another study found 60% to 80% of Vietnam veterans seeking PTSD treatment have alcohol use issues. They tend to binge drink in response to memories of trauma. Of further concern, veterans over the age of 65 who have PTSD are at a higher risk of attempting suicide if they also have an alcohol use disorder and/or depression.

People who experience trauma and PTSD often turn to alcohol and other substances to manage the intense flood of emotions and traumatic reminders. They may also use it to try to numb themselves. Drugs and alcohol may initially dull the effects of trauma and help manage associated distress, but a dangerous cycle may begin.

After a traumatic event, a person may drink to deal with anxiety, depression, and irritability. Typically, alcohol initially seems to relieve these symptoms. When we experience a traumatic event, the brain releases endorphins that help numb the physical and emotional pain of the event. This is our body naturally helping us cope.

However, this interrupts the natural protective function the body was already doing. As a result, we create a type of emotional withdrawal that can set us up to deal with increased and prolonged distress that could lead to the development of posttraumatic stress.

Drinking may have been the “solution” you turned to, but it is likely making things worse. We will not take that coping skill away until we teach you new ones.

Drinking often can contribute to PTSD symptoms and increase irritability, depression, and feeling off guard. Some drink to deal with insomnia that results from anxiety, anticipating nightmares, and circular thinking. Drinking actually impairs the quality of your sleep, however, setting up a destructive cycle. Trying to avoid memories of trauma can make them emerge in your sleep. Drinking also can make therapy less effective because you are not allowing yourself to effectively deal with trauma in a safe, healthy setting with a trained professional.

People who use substances may be less able to cope with a traumatic event. They may have increased difficulty with emotional and behavioral regulation. When chemical use starts, development gets significantly impaired. As a result, the person may be more likely to engage in risky behaviors that can lead to additional trauma.

The combination of trauma and drinking can increase challenges related to getting close to people and having conflicts with the people you do have a relationship with. Heavy drinking often leads to a confused and disorderly life. The very thing a person needs is support and connection, yet those are often damaged as a result of drinking consequences and behaviors.

A good therapist knows drinking is generally not THE problem. It is usually a symptom of another problem. Often, the problem is trauma. In such cases, drinking is not generally about having fun. It is about managing the pain of what you are dealing with.

Effective treatment of trauma does not mean you have to talk about what happened. We don’t want you to reexperience it. That probably happens enough. We focus more on how it is affecting you today. Drinking may have been the “solution” you turned to, but it is likely making things worse. We will not take that coping skill away until we teach you new ones. There are many other, more effective ways to deal with the past than drinking.

References:

  1. Bombardier, C.H., & Turner, A. (2009). Alcohol and Traumatic Disability. In R. Frank & T. Elliott (Eds.), The Handbook of Rehabilitation Psychology, Second Edition (pp. 241–258). Washington, DC: American Psychological Association Press.
  2. Khooury, L., Tang, Y. L., Bradley, B., Cubells, J. F., & Ressler, K. J. (2010). Substance Use, Childhood Traumatic Experience, and Post Traumatic Stress Disorder in an Urban Civilian Population. Depression and Anxiety. 27(12): 1077–1086.
  3. National Child Traumatic Stress Network. (2008). Understanding Links Between Adolescent Trauma and Substance Abuse: A Toolkit for Providers, Second Edition. United States of America.
  4. Trauma and Violence. (2015). Retrieved from https://www.samhsa.gov/trauma-violence
  5. Volpicelli, J., Balaraman, G., Hahn, J., Wallace, H., & Bux, D. (1999). The Role of Uncontrollable Trauma in the Development of PTSD and Alcohol Addiction. Alcohol Research and Health, 23(4), 256-262.

Dear GoodTherapy.org,

I am hoping you can give me an honest answer here. I have been seeing a therapist for nearly three years now and I just don’t feel like it’s working for me. I don’t feel any different than when I started. In some ways, I feel even worse, because I am discouraged about therapy not helping. It makes me wonder what is wrong with me that I can’t get better. I have read that it is highly unusual for someone to be in therapy as long as I have.

I guess I should provide some background about my “issues.” As a kid, I was molested for years by an uncle, saw my parents die, and was bullied incessantly. I have been told I have major depression and have tried about half a dozen kinds of medication, none of which have made a shred of difference. I have self-esteem problems. I can’t seem to hold down a job. I haven’t been in a relationship for five years; women won’t even look at me, and I don’t blame them. I hate my life and I have no friends. Yes, I have considered suicide. No, I am not currently suicidal. I know that distinction is important to people who do what you do.

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Because therapy isn’t helping me and hasn’t helped in all the time I’ve been in it, I want to stop. I feel like I am throwing away money. I feel un-helpable. I must be one of the few cases out there for whom there is no relief, whose problems are just too many and too major. I might be a lost cause. But I do not want to be a fool. My therapist has encouraged me to continue with therapy and to not give up hope. She says she has seen signs of progress but cannot seem to articulate them in a way that allows me to see them too. Maybe that is my failing, but I am starting to feel like maybe I’m just a paycheck for her. I don’t think she is necessarily a bad therapist. She is a nice person and she tries. She seems to truly care. I just think she isn’t helping me, I think she knows she’s not helping me, and I no longer really think anyone can.

What are your thoughts? Is she just stringing me along? Are there other people like me who don’t seem to get any better, and if so, what do you recommend in those cases? Please answer these questions. Thank you. —Lost Cause

Dear Lost,

What a great question regarding a terribly painful situation. I’m glad to hear from you about this, while so sorry to hear about all you have endured. Let me first give you my impressions in a way that “cuts to the chase,” then flesh things out a bit.

First, it is not unusual for it to take a while to find the right medication or combination of medications. (For instance, some people respond better to an older generation of medications, while others respond to SSRIs.) Have you tried more than one psychiatrist? I would encourage you to keep trying, discouraging as it has been. I have worked with a few people in therapy who were as discouraged as you, but managed to find an effective medication plan that helped them enormously.

You have been through hell and back. The fact you are still standing says something about your resilience. You have suffered enough trauma for several lifetimes, so it’s understandable you would feel this way. Your life experience has, I sadly observe, given you no tangible reason to hold onto hope. It does not mean there is none to be found, however; in fact, your letter indicates you are searching for it, itself is a glimmer of something positive.

As to your therapy question: Any therapist worth their salt would welcome any and all the feedback you have put forth here. My impression is it is time to have a blunt and honest conversation with your therapist regarding your feelings; if you’re still dissatisfied afterward, it may well be time to seek out someone new.

I would guess you had no source of true comfort after seeing your parents die. How unspeakably sad! I can hardly imagine a more hellish experience, in that the people you may have relied on most for comfort are the ones you lost. This, in addition to the other psychological injuries you experienced, leads to my amazement at your resilience. My great hope is you find, sooner rather than later, the kind of therapeutic “holding” and healing you deserve.

In the meantime, you seem to know intuitively you’re not getting what you need. I would be curious to know what keeps you in therapy with your current therapist. Have you tried telling her directly what you say in your letter? If not, why not? Is it possible she has helped as much as she can and now it’s time for a new approach? It is not uncommon, after all, to seek a second opinion medically; I believe this applies to psychotherapy also.

Sometimes people in therapy are afraid that, because they are not the “authority,” they do not have the last word on their own experience. You sound almost convinced it’s time to move on or ask directly that your therapist change her approach; I encourage you to follow your intuition. Whether or not it’s worth one last conversation with your therapist is obviously your call. Such a conversation could prove healing or just add fuel to frustration. If you feel you would benefit somehow from clearing the air, it’s worth a try. If, however, you feel it’s a foregone conclusion, you might want to move on.

Is it possible you doubt your own perceptions (not unusual with depression) in that she sees progress while you don’t, leading you to wonder if she is “right”? If the latter is true, she needs to find a way to convey her observations in a way that is meaningful to you. If your therapist insists you “hang in there” for no reason that feels solid, that’s simply not good enough; the direct experience of the person in therapy is, in my view, always front and center in therapeutic inquiry and exploration.

I don’t expect the people I work with in therapy to understand everything that flows from my lips. I have to learn a person’s language—and, to paraphrase Carl Jung, each of us speaks differently. I cannot insist on calling anything “progress” if the person in therapy feels or perceives otherwise. In the absence of mutual resonance regarding progress and therapeutic aims, the person in therapy feels dangerously alone.

Given your dwindling (or absent) faith in the process, it makes sense you are feeling alone in this relationship. It almost seems this alone-ness may even echo or parallel earlier suffering with the traumatic isolation and self-doubt you describe. I can’t shake the feeling you sense painful distance or discrepancy between you and your therapist, that she is missing something essential. I am not blaming her—nor you, for that matter. Do you somehow feel pressured to “live up to” her seeing progress? Are you concerned that if she feels disappointed or anxious about “progress,” it could be a bad sign?

Therapists seek a tricky balance between instilling hope and validating a person’s pain—mostly because, in so many cases, the latter has never been permitted or acknowledged by caregivers. Strangely, the more a pain is accepted as valid in the context of a person’s experience—with a safe other who can stay with you during and through that pain—the more healing the process becomes.

Therapists seek a tricky balance between instilling hope and validating a person’s pain—mostly because, in so many cases, the latter has never been permitted or acknowledged by caregivers. Strangely, the more a pain is accepted as valid in the context of a person’s experience—with a safe other who can stay with you during and through that pain—the more healing the process becomes. It’s when we begin to fear that emotional pain is “too much” for us or the other, or that it’s a sign of weakness on our part—that we need to “get over it already,” etc.—that it lingers like an unwelcome guest.

I believe people are entitled to all of their feelings, including and especially about therapy, because no one knows your experience better than you. I can’t imagine anything more important in your therapy than what you have bravely expressed in your letter. I am grateful you are not suicidal, but it sounds bad enough that an adjustment needs to happen, either within the current therapy or with someone new. (If thoughts of hurting yourself do resurface, please call 911 go to your nearest emergency room immediately.)

You sound very certain your therapist “knows she’s not helping me,” though I would urge you to not jump to the conclusion that no one can. The latter can be a hallmark or emotional symptom of depression—the sense one is cosmically alone in the universe, unable to connect with anyone. This feeling is, sadly, more common than many people realize. But this feeling is not objective “truth.” Your situation is not hopeless, and the fact you wrote your letter suggests you may leave room for hope, too. It is vital your therapist help you believe this more expansively.

When it comes to feedback, vital in any therapy, I try my best to listen nondefensively to where a person is or is not happy with me or how things are going with the two of us. My aim is to do no harm and be as helpful as possible. I do not assume I am always on the right track, or that no feedback means everything is fine and dandy.

There needs to be, more often than not, some mutually understood “map” of where we are going, and why—in your case, that would plainly include relief from traumatic anguish. The work can be difficult, even painful, at times, but for the sake of a treatment plan (ethically required), the “plan” needs to be something the person in therapy understands, endorses, and trusts as desirable.

Once a person begins to feel overly “protective” of the therapist’s feelings, which the therapist might tacitly encourage, the process is in danger of shutting down or becoming overly burdensome to the person, adding to their trauma and emotional isolation. Maybe the person has never had a chance to be fully honest with another, which can feel scary or even risky. The very act of sharing this disappointment can be healing, which is why I do my best to encourage it.

I would be curious to know if you are getting help with managing painful or traumatic emotions or emotional states between sessions. Do you need concrete help dealing with feelings of despair or low self-worth? There are cognitive behavioral approaches, dialectical behavior therapy (DBT), mindfulness, and other techniques to help with such moments.

Please do not give up. I wish you the best of luck in your pursuit of much-deserved relief.

Warmly,

Darren Haber, MA, MFT

Rear view of hugging female friends sitting in the parkThe dreadful memory may rush to your mind in an instant: taking a phone call from your child, partner, or friend and learning they were the victim of rape or sexual assault. Your mind may still be flooded with questions months or years later, and you may be struggling to move on from what happened even while doing everything you can to help your loved one move forward.

The support of friends, family, and significant others is essential to rebuilding trust and reducing shame in the aftermath of sexual trauma. In fact, loved ones are often the primary sources of support if a victim is not yet ready to seek therapy or explore other paths of healing.

As a friend, partner, or parent, you may feel lost or concerned about saying the wrong thing at the wrong time. Perhaps you wonder how to proceed with a conversation that may hold a great deal of pain for both of you. Consider the guidelines below on how to best provide nonjudgmental empathy, compassion, and support to a loved one who was raped or sexually assaulted.

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1. Let the Details Emerge at Your Loved One’s Pace

You may want answers: “Have you told the school administration?” “Do your friends know who the attacker is?” “Were there any warning signs that this was going to happen?” “Was there alcohol involved?”

Your loved one may not have even considered these questions, however, or may still be in a state of shock. Although answers may help you understand what happened, the focus should be on providing support for them. Also, consider how it might feel to be questioned in this way—it might evoke a sense of blame or guilt, as though a person could or should have done something differently to avoid the incident.

Let the details unfold naturally, on your loved one’s terms, and keep questions to a minimum. Recognize your loved one will share the details they find important to tell you—on their timeline.

2. Check In … Gently

As a psychotherapist, I hear many instances of rape survivors feeling disappointed that their friends or family no longer ask how they are doing in coping with their trauma. The most common reason for this seems to be some variation of, “I don’t want to bring it up since I know it upsets you.” It can indeed be upsetting, but that doesn’t mean it shouldn’t be processed.

Simple check-ins without prying for details—such as “I’m thinking of you today; how are your therapy sessions going?” or “Is there anything I can do to help with what you’re feeling?”—may reassure your friend, child, or partner they have your support. Although you might feel like you’re protecting your loved one by not asking how they’re doing, consider the possibility you are only protecting yourself from your difficult feelings while they are still struggling with their own.

Gentle check-ins can remind your loved one you are still an option for support, even months or years after the incident.

There is no “right” way to process and heal from sexual assault—for the survivor or for you. By providing gentle and nonjudgmental support for your loved one, you support them in taking back control.

3. Respect Their Choices, Even If You Don’t Understand Them

The best path to your loved one’s healing may seem obvious to you: “Take some time off of school, join a support group, press charges, and incorporate healthy activities!” This might be how you might choose to heal and move forward, but there is no one-size-fits-all approach to coping with trauma.

A large number of sexual assaults go unreported, and for a host of reasons: the victim may fear retribution, dread the thought of facing their attacker in court, or feel ill-prepared to have their most difficult life event publicized. By pressuring your loved one to handle things your way, you inhibit their ability to choose—an option that was also removed from them at the time of their rape or assault. It can be painful to re-experience this when a person is seeking support.

There is no “right” way to process and heal from sexual assault—for the survivor or for you. By providing gentle and nonjudgmental support for your loved one, you support them in taking back control. Remember: this person told you for a reason, and that reason was likely that they trusted they would receive unconditional love and empathy from a person who cares.

Your healing and processing are important, too. Be sure to practice self-care strategies and/or seek support from a therapist if you are struggling to cope.

Puddle of water on ground reflects blue clouded sky and person with hands in pockets looking down into puddleYou have explored your childhood emotional trauma, you have explored your triggers, and you have learned to reframe negative thoughts. You understand how your past experiences affect your behaviors, thoughts, and feelings today. You participate in mindfulness training regularly and engage in self-care continually. In other words, you have advanced quite far on your therapeutic journey to overcome previous difficulties. You have never felt better about yourself and you are proud of the insight into yourself that you have gained.

And then your new boyfriend breaks up with you and—BAM!—you’re suddenly having difficulty all over again. You worry about what you look like. You worry about fumbling over your words. You worry someone will see you trip on your shoelace. Your thoughts are a flurry. Confusion begins to seep in.

You worked so hard to overcome your childhood issues. You worked hard to reframe negative thoughts. You worked to learn good breathing techniques and implement them in difficult situations. But now you are face to face with the person you had long forgotten about. You look in the mirror and the person looking back at you says, “I’m still not good enough.”

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What happened?

Changing beliefs about oneself and improving self-esteem is difficult work. It can take months and even years to uncover, and reframe, cognitive distortions. Yes, you explored your childhood to learn the origins of negative thoughts. Yes, you learned to identify triggers and how to reframe irrational thoughts. Yes, your journey is on a new and healthy path and you feel wonderful each day. Whether it be good or bad, however, you are never without all of the events in your life that make up your history—and from time to time, history may pay us all a visit in ways we did not anticipate. We can become triggered.

A funeral can remind us of the long-ago passing of a loved one. The smell of cut grass can remind us of childhood days we miss. A song can bring about painful memories of abuse or trauma. A broken relationship may bring about buried feelings of abandonment. A new person in our lives may unexpectedly leave us feeling unsure of ourselves. We may suddenly become upset, anxious, or even depressed when events surface that bring about old memories and negative beliefs. We may feel we are reverting to old behaviors, thoughts, and feelings we had previously processed and moved away from, which can leave us feeling like we have somehow lost ourselves in the present.

We are never without our previous selves, no matter how much we may want to leave them behind. They may even visit us from time to time. From the words of a fellow therapist, when they return, say, “Hi, old friend. I know who you are. I know how you feel. Here’s how I can help.”

What to Do When You Feel Triggered

Healing is a process that has ebbs and flows. When you feel triggered, take the time to understand what triggered you and how you are reacting to the situation. What are you feeling? How is your body reacting? Do you have a “knot” in your stomach? Are you feeling panicked? Have you felt this way before? If so, when? Remember that when you feel triggered and old feelings and thoughts come rushing back, these moments will pass.

Review your previous therapeutic work. Revisit old ghosts and explore how they may be affecting you now. Explore previous feelings and how your current situation may leave you feeling the same way. Are there any similarities? Explore previous negative thoughts. Are you feeling less than? Do you feel unlovable? What in your history caused these thoughts? How is your current situation highlighting them again?

Review coping skills: reframing negative thoughts, deep breathing, mindfulness training, exercise, and other forms of self-care. We are never without our previous selves, no matter how much we may want to leave them behind. They may even visit us from time to time. From the words of a fellow therapist, when they return, say, “Hi, old friend. I know who you are. I know how you feel. Here’s how I can help.” Accepting yourself, past and present and all the flaws, is key to continued healing. Embrace who you are now … and who you once were, then.

faded grayscale photo of person with hand on head looking downWestern culture seems to be increasingly fascinated with the human brain. Emerging evidence in the field of interpersonal neurobiology links physiological processes of the brain with mindfulness and psychotherapy, and most of our efforts to understand illness, disease, creativity, innovation, attention and cognitive ability have long focused on the three pounds of flesh harnessed within our skulls.

The brain is only a small percentage of our body weight, but approximately 20% of our energy is required for its operation. Its three main parts, sometimes referred to as the “triune brain,” consist of the brain stem, the limbic system, and the prefrontal cortex. These parts, which evolved in that order, can be thought of as having “stacked up” over millions of years.

The Brain Stem and Limbic System

The brain stem, which is considered the foundation of the brain, travels up the spinal cord and connects to the brain. Because this initial part of the brain operates the basic systems of the body common to most lower-order animals, it is often called the reptilian brain. Processes of the brain stem include the functions most newborns are capable of: they can regulate the body’s temperature, experience pain, digest food, and monitor their breathing as well as heart rate and blood pressure. Babies do not have to think about these processes since they are automated by this lower order aspect of the brain.

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The brain stem is connected within the subcortical limbic system.  The limbic system can be considered a sort of “center house” for our emotional experiences, a registry for the things in life we move toward or away from. Also known as the mammalian brain, this aspect of the brain is contained within the middle part of the structure and is more evolved than the reptilian brain. The connection between the brain stem and the limbic system is what gives rise to the commonly understood defense mechanisms of fight, flight, or freeze.

The structure largely responsible for reactions to stimuli in our environment is the amygdala, a small, almond-shaped structure in the limbic system. This “smoke detector” of the brain determines whether a sound, image, or body sensation is perceived as a threat or is relevant to survival and activates the body’s stress response, or not, accordingly. When a noise that sounds like gunshot is heard, for example, then the body’s amygdala turns on, releasing stress hormones and nerve impulses to raise blood pressure, oxygen intake, and heart rate in order to prepare the body for fight or flight. An adverse noise can lead to a startle response, or goosebumps, perspiration, and the hair on the back of the neck standing up. The body responds in this way whether we actively think about these things or not.

The Prefrontal Cortex

What separates us, in a number of ways, from other animals is the prefrontal cortex, the so-called “human” brain. This structure lies just behind the forehead and is part of the larger neocortex that envelops the limbic system and contains all the other parts of the brain. Its overlap with the limbic system allows for an interplay between these systems and allows us to regulate our emotional responses.

When we hear a loud noise that could have been a gunshot, we startle, but the higher order processing of the prefrontal cortex allows us to reflect on the stimuli in our environment. After reflection, we might realize the sound was actually a car backfiring or a door slamming and regain a sense of calm. There is a dance of sorts that occurs between the prefrontal cortex and the limbic system. In general, the prefrontal cortex functions to regulate the body by balancing emotion, moderating fear, and granting us the ability to gain insight as well as a deeper understanding of morality, intuition and empathy.

Think back to a time when you were distracted, perhaps with your phone or by a child or partner, while grocery shopping. Executive functioning (discernment of the shopping aisles) becomes increasingly taxing when we are also engaged in a conversation. Our attention is split, and this can overload our working memory. When this occurs, the emotional part of the brain is left unchecked. Sometimes we leave the store and realize our shopping bags are filled with snacks and impulse purchases, not the items we had planned to buy. This occurs in part because shutting down the resources of the prefrontal cortex (talking on the phone) gives full autonomy to the emotional center of the brain, a non-conceptual framework focused on stimuli that grab our attention.

The Triune Brain in Relation to Mental Health

The three aspects of the brain can easily be associated with mental health treatment, psychotherapy, and mindfulness practice.

Individuals who have experienced traumatic events in their lives often have a limbic system (specifically the amygdala) that is overactive, in part because they can become fixated on flashbacks and memories associated with what happened. The ability to regulate and discern safety in their environment becomes challenging, to say the least, and the result of this is often a chronically activated stress response. The ability to name the emotion that coincides with an experience has been shown to decrease this amygdala firing, and psychotherapy, thus, often focuses on developing awareness of emotions within certain contexts in order to gain a wiser understanding of the reasons behind our typical reactions.

Engaging the prefrontal cortex to understand emotional habits and sequences is the essence of most psychotherapy. This top-down approach often has the effect of allowing us to connect with another person we trust and feel safe with. This modulation and intimacy that occurs in the context of a therapeutic relationship gives us the opportunity to comprehend what is going on internally while also helping us learn how to process those memories from our past we might rather avoid. The bottom-up approach to regulating experience happens by constantly returning to what we are doing in the here and now. The constant acceptance of “just this,” without any added judgment of whether we like or dislike what is happening, creates a kind of biological equanimity.

A path increasingly being traveled in contemporary societies is the disruption of symptoms via biological approaches. Pharmaceuticals have burgeoned as a method of altering psychological experiences in the West. Psychotropic medications such as Abilify have the effect of shutting down inappropriate alarm reactions, potentially changing the way the brain organizes information in the short term. The dampening effect of such drugs can provide a temporary solution to hyperactivity or dysregulation, but many find that using these medications prevents them from mastering their emotional responses and learning to self-regulate.

Developing the ‘Human’ Brain

Research suggests one way to exercise and strengthen the human part of the brain is to simply pay attention to the processes automated in our body. Recall the brain stem: it is essentially responsible for our breathing, so we don’t have to remember to breathe in the same way that we might try to remember to use the bathroom before going to a movie, for example.

The bottom-up approach to regulating experience happens by constantly returning to what we are doing in the here and now. The constant acceptance of “just this,” without any added judgment of whether we like or dislike what is happening, creates a kind of biological equanimity. The amygdala is less likely to sound its alarm as the prefrontal cortex becomes a better moderating feature.

Many studies have shown meditation practices create more of an approach orientation for individuals. We become less likely to avoid things and more stable within the storms of everyday life. This is not to say we will stop experiencing emotions and feelings. On the contrary, our senses are often heightened and deepened, and we are able to recover and navigate these moments in a more pointed and skillful way. Bessel van der Kolk notes in his book The Body Keeps the Score that for trauma survivors, a bottom-up approach allows “the body to have experiences that deeply and viscerally contradict the helplessness, rage, or collapse that result from trauma.”

We can use cognition to orient our attention to our experiences and discern how our actions have affected others, but for some, the prefrontal cortex, and the ability for self-reflection granted by it, is both an advantage and a disadvantage. We are able to dredge up the past and ruminate on our anticipated future, but with this comes comprehension of the temporary nature of our circumstances. In other words, we realize our own mortality: we know we will someday die.

Psychotherapy and mindfulness practices, then, merge as bottom-up processes for emotion regulation. Both are methods we can use to begin to recondition a habit or pattern of turning away from what is happening. An acceptance of the temporary nature of our circumstances and an increased focus on compassion, both for ourselves and others, are often direct consequences.

References: 

  1. Briere, J. N., & and Scott, C. (2013) Principles of Trauma Therapy: A Guide to Symptoms, Evaluation, and Treatment. Thousand Oaks, CA: Sage Publications.
  2. Siegel, D. J. (2010). The Mindful Therapist: A Clinician’s Guide to Mindsight and Neural Integration. New York: W.W. Norton & Company
  3. van der Kolk, B. A. (2014). The Body Keeps the Score: Brain, Mind, and Body in the Healing of Trauma. New York, NY: Penguin Books.

Overhead view of a person's legs in blue pants and feet in black and white sneakers standing in dandelion-spotted grassThe idea of seeking therapy after experiencing a traumatic event can be daunting. For some people, it can be almost as frightening as the trauma itself. Whether the traumatic event (or events) happened days, months, years, or decades ago, the prospect of facing it can make it seem like it was just yesterday.

If you are considering this path, it may be helpful for you to know we hold trauma and traumatic memories in the body. This means when you start to process sexual trauma (or consider processing it by starting to talk to a therapist), your body may start to have what we call “body memories.” As Peter Levine has explained, body memories can be described as a physical reexperiencing of the traumatic event(s). In other words, your nervous system and your body experience the feelings and sensations you experienced during the original traumatic event. These memories may be explicit (you have always remembered them) or implicit (not connected to a linear story line). Implicit memories can happen for any traumatic event and may be particularly common if you were under the influence of alcohol or drugs, were a child during the abuse, or if the abuse happened over a prolonged period of time.

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If you experience this, your therapist can help you learn how to practice bringing your awareness back to the present moment. One such example of this type of “grounding” is to bring your awareness or focus to your feet, saying to yourself, “My feet are on the ground. I’m present in this moment. These feelings are from the past.” This may sound simplistic or even silly, but this grounding technique can help you stay in the moment rather than flashing back to the past. Wiggling your feet and saying these simple phrases out loud may help to remind you that, regardless of what is happening in your body, the actual trauma is over.

For people who are not prepared to experience body memories when they start talking about their trauma(s), the shock of doing so may lead them to abruptly stop coming to therapy. It is uncomfortable, after all. They may reexperience post-assault symptoms in an overwhelming, rather than productive, way and fear becoming retraumatized. The potential for this is why I start all therapeutic relationships by establishing safety. Judith Herman, in her classic Trauma and Recovery, outlines the three necessary stages to any effective trauma resolution process: (1) safety, (2) remembrance and mourning, and (3) reconnection. That first piece, safety, is where developing the grounding skill happens.

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Other grounding and safety techniques may include the following:

The brilliant part about trauma therapy’s building of safety nets and grounding skills is it is limited only by one’s imagination.

Creating a compartment can be as simple as drawing a treasure chest where you imagine putting the traumatic memories when you are not in session, or as complex as a developing an end-of-session routine to keep the traumatic stimuli in the office so you can continue functioning in everyday life. This list is by no means exhaustive. In fact, the brilliant part about trauma therapy’s building of safety nets and grounding skills is it is limited only by one’s imagination.

Practicing the above won’t make the traumatic experience, or even the memories, go away. However, when practiced consistently, these skills—along with a consciously supportive healing relationship with a knowledgeable trauma therapist—can help you remain grounded. The ability to ground is the first step toward the reprocessing and resolution of sexual trauma rather than a retriggering of trauma and retraumatization in therapy.

References:

  1. Courtois, C. A., & Ford, J. D. (2009). Treating Complex Traumatic Stress Disorders: An Evidence-Based Guide. New York, NY: Guilford Press.
  2. Herman, J. L. (1997). Trauma and Recovery. New York, NY: BasicBooks.
  3. Levine, P. A. (1997). Waking the Tiger: Healing Trauma: The Innate Capacity to Transform Overwhelming Experiences. Berkeley, Calif: North Atlantic Books.
  4. Van der Kolk, B. A. (2014). The Body Keeps the Score: Brain, Mind, and Body in the Healing of Trauma. New York, NY: Viking.
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