Definition of Trauma: Exposure to an event which was perceived as intensely threatening to mind, body, or spirit, accompanied by feelings of helplessness, powerlessness and horror.
Trauma vs. Stress: Everyone experiences varying degrees of stress, including intense states of overwhelm. What distinguishes stress reactions from trauma is the degree of threat and the degree of helplessness. Frequently, stress brings us to the edge of our coping capacity, but we’re still able to think and function to some degree. With trauma, we are paralyzed, unable to respond, unable to marshal strategies of protection or action. The world has presented us with a situation that we cannot understand, master, or respond to.
Types of trauma
Type I (Simple): Single incident, short-term, unexpected, high threat, overwhelming (i.e., rape, natural disasters, surgery, illness, car accidents, violent assault, shooting, industrial accident).
Type II (Complex): Exposure to a series of traumatic events, or ongoing conditions of deprivation; more likely to be human in origin (i.e., childhood physical and/or sexual abuse, combat, p.o.w, kidnapping, torture, organized sexual exploitation, spousal abuse).
Trauma through Neglect (Developmental)
A broad range of adverse events that occur in childhood, such as being abandoned, rejected, betrayed, abused (physically, emotionally, or sexually), witnessing violence or death, being coerced, or having threats to bodily integrity. Good-enough care (meeting a child’s emotional, physical and psychological needs) is necessary for secure attachment. Attachment theory posits that the caregiver-infant bond is the essential and primary force in infant development, and thus forms the basis of coping, negotiation of relationships, emotional regulation, and personality development. If attachment is compromised by neglect, the infant’s brain does not receive the stimulus or the modelling it requires for optimum development, and certain stages of growth are arrested.
Betrayal Traumas: Betrayal trauma occurs when the people or institutions we depend on for survival violate us in some way, or do not adequately meet developmental needs. An example of betrayal trauma is childhood physical, emotional, or sexual abuse. Betrayal trauma theory posits that there is a social utility in remaining unaware of abuse when the perpetrator is a caregiver.
- Primary sources of trauma
Societal trauma: crime, molestation, murder, war, torture, genocide, terrorism.
- Medical trauma: Re-experiencing and intrusive memories of particularly traumatic scenes from medical interventions are common in all ages; both neonatal and pediatric stress responses occur in surgical settings.
- Chronic disease: By definition, diseases are a threat to life and often invoke a state of helplessness and horror.
- Disaster: Natural or otherwise (flood, fire, hurricane, etc)
Factors affecting the degree of impact of trauma
- Support system vs. secondary traumatization
- Degree of assistance from professionals
- Relationship with perpetrator (if applicable)
- Perception of one’s response to event (how self-blaming survivor is)
- Degree of cumulative stress at time of traumatic event
- Number of unresolved traumatic incidents already experienced previously
- Locus of control (internal or external). Degree of helplessness experienced
- Degree of dissociation
- Degree of self blame
Prediction factors of PTSD
85% of traumatic experiences are spontaneous remissions.
The following factors are highly correlated with development of PTSD
- Peritraumatic dissociation (dissociation during traumatic incident)
- Degree of threat experienced during trauma (the most intense fear is that of death)
- Attachment in childhood (Secure, Avoidant or Ambivalent).
- Prior traits of Anxiety-Neuroticism
REACTIONS DURING TRAUMA
In the moment of high stress/trauma, people have ONLY three options:
1. Flight 2. Flee 3. Freeze 4. Fawn
The body’s survival mechanisms operate from the old brain (limbic system) and are automatic. The frontal cortex, with all of its evaluative ability, is not employed to do a cost-benefit analysis of the best course of action. The responses above all have adaptive qualities, and are geared to ensure survival in a time of perceived danger. In each case, the body and brain are pumped full of chemicals such as cortisol and adrenaline. These chemicals allow the body to behave in extraordinary ways, such as super-human strength, or the ability to hold still, but if they are not dissipated through emotional discharge, they dysregulate the neuro-chemical balance of the brain.
Freezing/Fleeing: For young people and women, fighting is not generally adaptive, as the chances of winning are small. In nature, only the really big animals fight. The others flee or freeze. In humans and animals, 90% of the responses are to freeze. Humans often freeze physically and flee mentally, separating from the feelings that are too overwhelming to bear. This state, where one leaves one’s body and feeling state is called dissociation, and it allows the survivor to keep herself split off from the trauma. It is often the best, most adaptive response available, but unlike animals, we humans look back and say “I should have….” And we blame ourselves, “shoulding all over ourselves”.
Fawn: This term was coined by Peter Walker and refers to trying to gain favor by acting servilely; to cringe and flatter or to show affection in a solicitous or exaggerated way in an attempt to please. These are survival strategies where the dependent one will do whatever their depended-upon person needs them to do, or to be, in order for the dependent one to have their own basic needs met
SYMPTOMS OF TRAUMA
Responses to traumatic events can be delayed for months or even years after the event. Often, people do not even initially associate their symptoms with the precipitating trauma. The following are symptoms that may result from a more commonplace, unresolved trauma, especially if there were earlier, overwhelming life experiences:
- Eating and sleep disturbances (more or less than usual)
- Sexual dysfunction
- Low energy
- Chronic, unexplained pain
- Depression, spontaneous crying, despair and hopelessness
- Anxiety, panic attacks
- Fearfulness; feeling out of control
- Compulsive and obsessive behaviors
- Irritability, angry and resentment
- Emotional numbness
- Withdrawal from normal routine and relationships
- Memory lapses, especially about the trauma
- Difficulty making decisions; decreased ability to concentrate
- Feeling distracted
- Chronic negativity, fearful thoughts, sense of doom, anxiety
Spiritual and Social
- Decreased sense of worth, meaning, value “existential angst”
- Increased isolation, fear of trusting others
- Betrayal by God or Higher power
ADDITIONAL SYMPTOMS ASSOCIATED WITH SEVERE TRAUMA
The following additional symptoms of emotional trauma are commonly associated with a severe precipitating event or chronic trauma, such as a natural disaster, exposure to war, rape, assault, violent crime, major car or airplane crashes, or child abuse. Extreme symptoms can also occur as a delayed reaction to the traumatic event.
Re-experiencing the Trauma
- Intrusive thoughts
- Flashbacks or nightmares
- Sudden floods of emotions or images related to the traumatic event
Emotional Numbing and Avoidance
- Avoidance of situations that resemble the initial event
- Detachment from self, others
- Feelings of guilt, grief, depression
- An altered sense of time; a fore-shortened sense of future.
- General anxiety; hyper-vigilance, jumpiness, an extreme sense of being “on guard”
- Overreactions, including sudden unprovoked anger
- Obsessions with death
NEUROLOGICAL IMPACTS OF UNRESOLVED TRAUMA
Bi-phasic Nature of Trauma
The neurophysiological and neurohormonal events of trauma change the central nervous system, alternating between numbing (endorphinergic influences) and flooding (adrenergic dominance), constituting the basically bipolar (numbing and flooding) and self-perpetuating nature of PTSD. Part of trauma treatment is learning skills to regulate emotions such as fear, anxiety, and hopelessness, so that the swinging from super-aroused to super-numb is diminished.
Neurological Processing During Trauma
During the time when the body/mind is experiencing extreme disturbance and is flooded with chemicals, experiences and perceptions are recorded in the brain in a different way. The release of neurotransmitters in the brain inhibits the usual encoding mechanism, and the “thinking” brain is hi-jacked by the “survival” brain. Unlike ordinary experiences, which are organized cognitively and verbally, trauma is organized in memory on sensori-motor and affective levels. This failure of information processing to categorize and integrate traumatic experience with other experiences is at the very core of the pathology of PTSD. The “trauma data” remains “live” and has not been metabolized or “made sense of”.
Meaning: Because it is not processed, meaning is not made, as is usually the case when experience is evaluated, categorized and organized into meaning by the frontal cortex. The brain’s job is to make the world make sense to us, and it continues to try to resolve all the jumbled data inside, but is usually overwhelmed by it, and unable to defuse the chaos. Some survivors may process the trauma to resolution right after the event; however, many are not able to, and the body and mind must therefore carry the experience it can’t resolve.
Container: In order to function at all with the live, detailed, raw data inside, the mind must wall it off, and contain it. The passage of time does not reduce the disturbance inside and the feelings do not subside, they are simply buried alive for a time, but are always there, under the surface, until fully resolved. The memories and sensations are so abhorrent that many people split away from the body and mind, trying to keep the trauma repressed and contained. This is normal, but again, inhibits the encoding and processing of the information towards resolution.
Leaking: Attempts to keep the material repressed do not always work as there are reminders and environmental triggers. It is also extremely exhausting, and most people are unable to keep the material from leaking, or bursting through their defenses, usually in response to an environmental cue, in the form of nightmares, flashbacks and hyper-arousal. They are flooded with pictures, memories, sensations of the original trauma, and it may feel like its happening al over again. Survivors continue to function as best they can, carrying the trauma response inside, until such time as they have enough resources and stability to face and process the pain. Often, during this stage, survivors will be told to “get over it’ and stop living in the past” when in reality the past is living in the survivor, and they don’t know how to stop it.
Coping: When survivors experience a state of high neurological and physiological arousal, it is acutely uncomfortable. The survivor will use any method to reduce the arousal and return to a numb sate, where she feels more in control. In order to externalize the feelings, that is, to get the pain from the inside to the outside, a survivor may engage in self harm. The pain caused by the survivor may distract from or release the pain inside. The goal of all coping is to move back into a state one can tolerate and that is familiar; however, some coping methods are more destructive to the self than others. The goal of therapy is to learn and consistently use supportive coping to handle the intense emotions left from trauma.
Hyper-vigilant: Trauma experiences shake the foundations of our beliefs about safety, about people, about the world and about ourselves. A primary instinct/urge in humans is safety and preservation. In order to avoid further traumatic experience, the body automatically goes into a state of hyper-vigilance and sets up very sensitized radar. The body and mind are constantly on alert for any situation that seems similar, so that it can be avoided or controlled. Because this is so painful and/or exhausting, survivors often become avoidant, isolated, controlling, and unable to take risks or to connect interpersonally. In this state, when danger is assessed, and/or the survivor is triggered, she will typically follow the previous pattern of dissociating to escape the psychic pain. In this cut-off state, the survivor is less able to think clearly in the face of new dangers, and is vulnerable for further victimization
Initial stress responses spark changes in the brain’s chemistry and limbic system so that the nervous system becomes more excitable and more easily activated, and is prone to respond to environmental cues as if they were threatening when in fact they may not be.
Theory of Mutual maintenance between PTSD and Chronic pain
In this feedback loop, pain serves as a reminder of the trauma, which increases anxiety, and the release of stress hormones. In turn, chronic levels of anxiety and arousal from PTSD make the sufferer more sensitized to pain.
Dissociation is a “defensive disruption in the normally occurring connections among feelings, thoughts, behavior, and memories, consciously or unconsciously invoked in order to reduce psychological distress” (Briere, 1992). If an event becomes so threatening that our psyche simply cannot stay present without decompensating (rather like too much electrical current flowing through a circuit), the system automatically “turns down consciousness” so that the brain does not melt down. The disturbing material is “set apart” from the self, so that the self is protected. Another way that people dissociate is to remove the part of themselves that received the trauma. In this scenario, the body often becomes dangerous to inhabit. Disorders of consciousness and attention: Depersonalization, Derealiztion, Dissociative Identity Disorder.
Conversion occurs when intolerable levels of anxiety are converted into symptoms in organs or other parts of the body, often resulting in “illness” which is not easily detected by standard allopathic medicine. Implications for bodywork and energy work.
The unconscious tendency to repeat previously traumatic experiences or dynamics, in order to gain mastery and have a successful exit. Also called “repetition compulsion”.
APPROACHES TO TRAUMA TREATMENT
Traditional approaches to treating emotional trauma include:
- Talk therapies (also termed “cathartic” as they rely on working out the feelings associated with the trauma);
- Cognitive-Behavioral Therapy (CBT) involves changing one’s thoughts and actions, and includes systematic desensitization to reduce reactivity to a traumatic stressor;
- Relaxation/stress reduction techniques, such as biofeedback or breathwork; and hypnosis to deal with reactions often below the level of conscious awareness.
- Process and psych-educational groups: participation in contained and safe environments where normalization, skill-building, integration and self-acceptance occur.
Depending on the nature of the trauma and the age or state of development at which it occurred, these somatic (body) psychotherapies have proven very effective
- EMDR (Eye Movement Desensitization and Reprogramming; Ellen Shapiro)
- OEI (One Eye Integration)
- Somatic Experiencing (Peter Levine)
- EFT (Emotion Freedom Techniques; Gary Craig).
- TIR (Traumatic Incident Reduction; Frank A. Gerbode).
- Hakomi (Mindfulness and bodywork; Ron Kurtz)
- Integrative Body Psychotherapy and body work of all types.
STAGES OF TRAUMA THERAPY
1. Capacity Building and Grounding techniques
Allow clients to focus on transforming the energy of invasion into the energy of creation. In order to ensure safety in the healing process, the focus of treatment is initially on building a persons self-capacity and ability to regulate emotions and remained grounded in the presence of intense pain. A person starting therapy generally feels that the trauma outweighs their skills, resources and sense of self, and so it is cubical to build these skills:
- Building safety in the client’s life (ending self and other harm)
- Reducing the bi-phasic swings from numbing to flooding;
- Stabilizing medication (as relevant)
- Regaining control (of body, emotions, thoughts, actions)
- Introducing the concept of curiosity, dual awareness, self-compassion
- Developing therapeutic alliance
- Knowledge acquisition (trauma theory; impacts of trauma, thriving coping skills)
Capacity building includes the following: identifying strengths, resiliencies, gaining knowledge about the nature and impacts of trauma, building a support network, beginning to journal, to practice self-regulation skills such as visualization, 5 to 1, container, shield etc. as well as to become more grounded through meditation, yoga, breathwork, affirmations.
2. Emotional Processing and building new narrative of self
When self-concept and capacity has increased substantially, and roughly equals the size of the trauma, it is not safe to begin processing the trauma memories in a carefully paced (titrated) method.
- Telling the story of what happened, and processing emotions which have never been expressed. Therapist must ensure that the telling is therapeutic; that the re-telling is allowing healing, and is not a rehearsal or re-enactment of the pain.
- Taking the support of an ally into the darkest places and installing new resources and restructuring cognitive schemas
- Grief and mourning
- The focus is on getting back out into the world, engaging wherever there may have been withdrawal from participation in order to live the highest potential
- Bringing all parts of self together cohesively, including disowned parts. Development of new identity as resilient, as a survivor
- Connecting again to self, others, community, meaningful work
- Giving back to other survivors
TRAUMA RECOVERY CRITERIA
- Authority over memory: Trauma experience is a cohesive narrative, and the memories surrounding the trauma can be put aside or remembered at will.
- Integration of memory and affect: Able to remain connected to feelings, but not become overwhelmed by them. Capacity to tolerate feelings even when trauma experience is triggered.
- Self esteem: Accept, value, acknowledge self. Self blame is minimal
- Symptom mastery: Demonstrate variable thriving coping mechanisms and ability to make healthy behavior responses. The physical symptoms are alleviated or at least manageable.
- Self Cohesion: Integrated sense of self; the acknowledgement of all parts of the self, no longer disconnected from certain aspects of self.
- Safe Attachment: Have safe, intimate relationships over long periods of time
- Meaning making: comprehension, understanding, acceptance, self-valuing; the story of the trauma has meaning in the person’s life.