Resilience and Recovery during CV19 in Victoria

As a psychotherapist writing about and witnessing the emotional and human toll of CV19 in Victoria, I have been asked my thoughts on “resilience”. Helen Clark co-chair of the WHO’s Independent Panel for Pandemic Preparedness and Response, recently stated that the recovery may be delayed by up to two and a half years.

To sustain positivity and resilience during this time seems a huge ask. This is not going to be a “think positive” situation for many people, and It seems disrespectful to ask people who are struggling to be resilient right now. Honouring and dignifying their real suffering and distress seems more appropriate at this moment.

However as a psychotherapist specializing in helping people recover from complex trauma and PTSD, I do know that there is a lot people can do to nurture, soothe and support themselves, and to enable resilience and recovery even from the most complex of situations over time. Some of the suggestions below may be surprising.

First: become more “selfish”. The very first thing to collapse when people are highly stressed is self- care. Many people tell themselves “I’ll take better care of myself when I’m less tired, stressed, busy, anxious or depressed. I will drink more water, eat healthier food, do some exercise then”. Unfortunately, this does not work- though many of us have tried it. Instead, the stress or symptoms typically get worse over time if we are not somewhat “selfish”. This applies to those working at the front line of this crisis, but equally to others who are feeling the stress of being locked down or cut off from usual supports. So go on, try being more selfish and do self-care even if you don’t really “feel like it”. Remember the oxygen mask drill on the plane and take care of yourself first.

Second: Avoid too much avoidance, get real. Studies have shown that avoiding uncomfortable feelings or situations builds up and makes things worse over time. A healthier approach would be to take a leaf from the sixties and “keep it real man”. When friends or family call to see how you are, be real with them. Don’t wallow in self-pity, just be as honest and straightforward about how you are really going as the relationship allows. If the relationship doesn’t allow much authenticity, maybe it’s time for an upgrade? Or speak to those one or two that you really trust? Or even seek out a new tribe to belong to?  You have time during lockdown to research this!

Third: You only have to get through one day at a time Yes, I know this is stolen from AA, but it works during CV19 too… I don’t think they would mind us borrowing this solid gold idea.

Fourth: Build more scaffolding, structure or resources into your life. Scaffolding can be people, creative outlets, pets, nature, studying something, having more time off, or having a timetable. Scaffolding can also simply be your body or posture, think of Amy Cuddy’s TED talk on experiments with lengthening the spine for two minutes. Think about what you need to get out of Groundhog Day, to feel stronger, more resourced or braver. Everyone needs more scaffolding when times are tough.

The mind-body connection

Image from The Developing Child, Harvard, 2020

Fifth: Avoid too much stimulation/distraction with screens. The brain and nervous system need to “rest and digest” every day, otherwise cortisol levels keep rising in the body throughout the day and peak at night, disrupting sleep quality. Screens also emit the wrong sort of light visually into our brain and decrease the natural production of Melatonin which makes us sleepy. Try to avoid screens for at least two hours before bed, reading a book is ok, and listening to things like the Calm App sleep stories has helped many a poor sleeper get better sleep.

I hope these ideas point toward how we can better care for and protect ourselves during these trying times in Victoria. Remember, the suffering is real. Let’s not minimise what we are going through together right now, but be tender, respectful and caring toward ourselves and others in the midst of the great fight of our lifetime.

Toxic Masculinity and Trauma

Toxic masculinity as a cause of complex trauma has been well described, yet still it flourishes at all levels of society, and not only via toxic men but also by toxic women like Ghislane Maxwell who dance figuratively around the “maypole” of phallos to support them, and toxic systems such as the legal system which enables the perpetrators to be largely unaccountable while victims are further crushed and humiliated by the court system.

We know more about toxic masculinity today. The MeToo movement and books like Jess Hill’s “See What You Made Me Do- Power, Control and Domestic Abuse” have exposed how hard it is for women to push back against coercive control or abuse. Louise Milligan’s book regarding George Pell and the farce that was his legal proceedings, show how the most vulnerable women and men simply cannot rely on the court system to protect them.

Indeed, many clients over the years have tried to report sexual assaults or even organised/ cult sexual assaults to authorities. Invariably not only are they not helped by the police or legal system, but usually further retraumatised, humiliated and dismissed by the very system they turn to for help, and sometimes further put in harm’s way by these authorities.

Today in 2020 in Victoria, police are supposed to charge the abuser in situations of domestic violence, and ensure the safety of victims and children, but despite the change of law following Rosie Batty’s family violence Royal Commission, many police still leave it to the victim to press charges and fail to protect the children. Child Protection services are also ineffective, partly because our toxic politicians claim they can’t afford to fund it properly. Yet as we have seen in the CV19 era, there is plenty of money available when the government wants to spend it.

There is also at least one health professional I know of who uses his position of power to groom then violently abuse female clients who are particularly vulnerable. All done under cover of his particular specialty, and the power and authority of international recognition as an expert. Yet again, the College he belongs to would not protect his victims, so it is not safe for the victims to report him.

It seems that power does corrupt, absolutely.

In the eighties and nineties, partly in response to Jungian writers and themes of the era, some men’s groups attempted to heal the pattern of toxic masculinity via group work, often involving initiations such as treks, sweat lodges and other rites of passage, holding each other accountable for their shitty behaviour. But these too have largely fizzled out. The Men’s Behaviour Change programs are frequently ineffective even when men are mandated to attend. The problem, as set out in Jess Hills book, is the entitlement and lack of accountability of toxic masculinity.

With the world facing a global epidemic of toxic masculinity now, which is also destroying the planet through climate change, I ask myself WHERE ARE THE GOOD MEN?

“The only thing necessary for the triumph of evil is for good men to do nothing” attributed to Edmund Burke, (originally from John Stuart Mill, 1867.)

Women have tried to help and educate men for decades, but they are done with trying to help or educate men on their own. It is up to good men to educate themselves now, to show up with women, and to stand firm against toxic masculinity together. Now is the time for good people to come forward to save society and the planet.

Feeling Too Little and Addictions

In the previous blog I illustrated some of the symptoms following complex trauma, including  feeling too little, the topic of today’s blog. Today I discuss the role of addictions in helping people to survive or numb out emotional pain, and offer some ideas on how to support the healing of addictions.

Firstly, healing addictions requires a lot more than just stopping the habit or pattern. The work of healing addictions includes a developmental/behaviour component to be healed, for example the “Puer Aeternis” (eternal youth) first described by Jung over a hundred years ago, which from a structural dissociation perspective would include the “collapse” and “flight” fantasy self- state.

Mills and Teason (2019) report that a history of trauma is almost universal among people with addictions using AOD services. Some theories suggest that self- medication of trauma symptoms like anxiety may play a role in the development of addictions. Other theories suggest that addictions are part of the magical thinking and “flight” of the younger parts of trauma survivors, helping them to escape unbearable pressure or emotions. Another idea (generated by observations within my work) is that sometimes the addictive habit or pattern is an unconscious attempt by a younger part to find an idealised “attachment” figure, (the addiction for example to cigarettes or alcohol) perhaps offering an alternative or fantasy “friend” to relate to, where they can have a special relationship, gain significance, or just find solace from everyday life. Some of these ideas are contained in the Puer Aeternis character pattern described over a hundred years ago by Carl Jung.

So if the addiction offers the fantasy escape from pain and suffering, it stands to reason that people with addictions will need to add other supports and skills to replace the “escape hatch” of the addictive substance or behaviour. We cannot expect people to give up substances and habits which they believe are vital for their survival. Addictions may be the best method the person has for surviving at first! Janina Fisher illustrates why additional “scaffolding” is needed below.

The worst part of addictions are that in the long term they damage the relationships that could powerfully help to heal trauma symptoms, cause health problems and shorten life expectancy. Worse, over time the addiction can become a “substitute relationship” while real relationships are sidelined, making the person increasingly cut-off and lonely.

 

Whatever the reason for the addiction, recovery from addiction and feeling too little takes time and work. Simply stopping the addictive pattern eg via willpower is not enough, although its a start. Significantly, work is needed around the trauma and the individual factors that hold the addiction in place, as well as building more supports and skills. This work is best done with a therapist or group that is well trained in contemporary trauma theory as well as addictions. You can also contact organisations like Odyssey for more information.

 

Changing Patterns and Habits

Neuroplasticity can help solve a lot of problems, but it can also create problems! Some patterns or habits of thinking, feeling or responding can start off as helpful but because of  stress and neuroplasticity become rigid, harder to change, or simply less helpful over time. Patterns or habits such as overworking, avoiding certain things, irritability, or always putting the needs of others before your own can become “set in stone”. Because these patterns have happened thousands of times, they may feel like “this is the truth “or “this is who I am”.

 

But all patterns and habits are neuroplastic and so can be softened, changed, or even eliminated if that is what we want. To modify any habit, we need commitment, but with persistence we will ultimately be successful!

Let’s start by identifying some common mental patterns and habits that may start off innocently but take on a life of their own and cause problems:

Common mental habits or patterns:

  • worry or rumination
  • problem solving orientation, including problems that haven’t occurred yet
  • wishing things were different
  • idealising others or yourself
  • needing to control how others see you
  • rigid or black and white dogmatic thinking
  • unexamined beliefs eg
    • believing things because you were told them as a child (introjects)
    • believing things because you wanted them to be true (magical thinking)
    • believing things because someone you liked or looked up to believed it
  • catastrophizing
  • automatic advice giving
  • allowing the mind to be busy all the time
  • avoidance eg spending excessive time in a fantasy world or day dreaming
  • harsh self-attack or self-criticism
  • perfectionism
  • fuzzy or magical thinking instead of clear thinking when faced with problems
  • justifying or defending habits that aren’t good for you!
  • other mental patterns or habits not listed above, that in some way cause pain, stuckness or distress to yourself or others.

Reflections:

Looking at the list of mental patterns, do any stand out for you?

What sort of commitment or small steps would it take to soften or change this pattern?

How long would you have to persist with new patterns for them to become established?

I would love to hear from you if you are trying to change habits or patterns now.

 

 

 

 

Co-Dependence and Addictions

In Codependence, relationship and life problems become worse over time.

These roles of victim, rescuer and persecutor are often caused by intergenerational trauma or unfairness. What holds these three roles together is denial. At some level, Persecutors have convinced themselves they are right to do what they do to the Victim and refuse to see their actions as abusive or manipulative. Victims wonder how they ‘always end up in this situation’ and feel both powerless and blameless. Rescuers tell themselves they ‘are just trying to help’ and are ‘good people’, when really they get to control by keeping Victims helpless or feeling needed. Davis and Frawley discovered that there is also a fourth position called the passive or neglectful bystander. All of these roles are interchangeable, and none of them are healthy.

To heal this relationship pattern, we need to practice doing the opposite of what we normally do.  The opposite of the destructive-fuelled by control, guilt and enmeshment, as in the co-dependence pattern above, toward a better way of loving that honours us and the people in our lives.

An honest look at the behaviour patterns we’re engaged in is often helpful. But don’t expect those around you to want to change the pattern even if you do! This pattern is often called the Drama Triangle!

Things to be curious about

  • When you were growing up, what sort of role did you play in the family?
  • What aspects of self-did you or others -have to deny, in order to play that role?
  • Do you still play the same role today, or have you adopted other roles?

To escape the co-dependence pattern I suggest that you start by learning positive skills and boundaries for yourself and others as illustrated below.Interdependence the solution for codependence

I hope this blog evokes curiosity and perhaps even a moment of clarity and self compassion. More help with changing patterns is available through CoDA or Al Anon, or via a trauma therapist on sites such as the Blue Knot Foundation or addiction therapy groups via organisations like Odyssey. 

 

 

The Aftermath of Trauma

The infographic below illustrates why healing trauma is not “one size fits all”. The aftermath of trauma can vary widely. In coming weeks I will explore each section and discuss a little of what is needed to heal each set of symptoms.

 

An Alternative Framework for Mental Health

For many years I wanted a better framework for best practice than the current bio-medical model which pathologizes symptoms of complex trauma as a “disease” and “biological” state-without evidence! Apart from the disrespect inherent in putting labels on people who have already suffered multiple adverse experiences, it doesn’t make sense that this reductionist way of supposedly helping people is often causing more harm, leading to ongoing Royal Commissions that never seem to address the underlying structural problems in mental health care.

In Australia, the structural problems – including professional “language” and treatment approach for mental health- are driven by the DSM- the Diagnostic and Statistical Manual, revised and produced every few years by the American Psychiatric Association.  Within DSM criteria, people with complex trauma are often misdiagnosed or given labels like borderline personality disorder, Bipolar disorder, depression, generalised anxiety disorder, causing many kinds of mistreatment and mismanagement (Benjamin, 2019)

DSM started as a valiant way to understand mental health issues, developed by  Americans who didn’t like the flowery language of the existing International Classification of Diseases (ICD). However since then it has been largely taken over by white, middle-class US psychiatrists closely aligned with big Pharma. Since the eighties, Big Pharma has been gradually expanding the range of conditions classified as “disorders” in order to sell more drugs (Moynihan, 2018)

Hospital/service funding and practice now follows from these un-validated and unreliable labels, implying that one just needs to tip the right chemical into a brain to “sweeten” it. Those that can’t be “sweetened” chemically are called “outliers” by the system, or stigmatised for being “treatment resistant”, treated harshly in EDs or discharged prematurely even though very unwell or at risk. Psychotherapy is considered only as a last resort. Some of these people become the homeless that wander our street, mistrustful of the very services they have earlier turned to for help.

International trauma experts like Dr. Bessel Van Der Kolk struggle to be heard over the vested interests who find profit and convenience in the current DSM system. Multiple inquiries into mental health over decades show this system is not working. Marginalised groups such as mental health consumers seem invisible to DSM oriented practitioners. It is faster, easier and more profitable to offer drugs like “Quietipine” (to quieten the patient), than to sit beside those who are suffering or try to understand trauma systemically.

A huge shortcoming of the DSM model is that it locates the problem solely in the person, and ignores the systems and environment that created the problem in the first place. As identified by the Division of Clinical Psychology (DCP) of the British Psychological Society:

“The DCP is of the view that it is timely and appropriate to affirm publicly that the current classification system as outlined in DSM and ICD, in respect of the functional psychiatric diagnoses, has significant conceptual and empirical limitations. Consequently, there is a need for a paradigm shift in relation to the experiences that these diagnoses refer to, towards a conceptual system not based on a “disease” model.” (DCP, 2013, p. 1)

Indeed, the DSM system is so low in research validity and reliability that two of the largest international research funding bodies have stopped allowing DSM criteria as the basis for medical research. However organisations that promote DSM are very powerful and influential, with deep pockets and ongoing political lobbying.

The Power Threat Meaning Framework developed by members of the British Psychological Society offers a new and compelling alternative to the DSM, that appears to have a more valid and ethical way of making sense of trauma symptoms without “labelling” of symptoms including mental distress, unusual experiences and problematic behaviour. It was developed over a five year period in the UK, by researchers who looked for an evidence base for best practice in working with trauma – supported by what we know from decades of research about the causes of trauma, which are often transgenerational and systemic.

Trauma is exacerbated by disrupted early attachments and imbalances of power and the inherent inequalities that lead to abuses of power and privilege. They assert that the many symptoms of trauma are simply a survival-based adaptation to the original situation, for example hypervigilance or dissociation originating from having to survive an unpredictable or unsafe environment. This view is shared by many international trauma experts including Bessel Van Der Kolk, Janina Fisher, Pat Ogden, Lou Cozolino and Judith Hermann.

Recently the Australian Childhood Foundation sponsored the author of the new framework to speak to professionals and consumers about this model. More information about this model can be found here in power threat meaning framework intro 2018, written by the authors of the study.

The authors

Sexual Abuse-Healing the Aftermath

Healing and the Aftermath

Sexual abuse creates long term problems for many people, which may not show up until years after the abuse. Abuse can be open or subtle, can be part of a “special relationship” or secrecy. The victim may be blamed by the abuser for the abuse, or worse, be told that this is “love” or that they somehow  “deserve” the abuse.

ABUSE IS NOT LOVE!

Ross and Halpern (2009) describe many of the effects of  childhood sexual abuse. Abuse impacts the development of the sexual and personal identity of the victim in profound ways, even if the survivor can’t remember the abuse at all. Common problems include a sense of discomfort with one’s femininity, masculinity or other orientations, being uncomfortable in one’s body, hypersexual or hyposexual behaviour, alteration in how a person dresses or grooms, sexual addictions, anxiety, depression, dissociation, or confusion around sexual orientation.

On the emotional level, there is often self -blame, self- doubt or self- attack. People wonder if there is “something wrong” with them (shame or guilt). There may be fear of sexual arousal or the content of sexual fantasies. People often question whether their fantasies or behaviors are normal. Others avoid sexuality and intimacy to protect themselves. Others may dissociate from their body altogether and become a “walking head” as a survival based response.

Adding to this, any form of sexual contact, even sexual thoughts, can trigger anxiety, guilt, shame or flashbacks of past abuse. This can be frightening and distressing for the person. The situation may also be distressing for their partner who may be the unwilling, and often unknowing, catalyst for flashbacks, and who may be cast in the role of the perpetrator. This puts painful strain on both people in the relationship.

Some people do not have flashbacks but instead experience a range of problems with arousal, orgasm, or have other difficulties with sex. Boundaries with others may be confused. Intimacy or connection become complicated. Some experience gender dysphoria or gender identity confusion. Others may be fused with their partner and find it difficult to say “no” or to be an individual, while others convince themselves they don’t need anyone. Trust is often be a major issue.

Miraculously, I have seen many people with symptoms of trauma like this make changes, even late in life, that transform and heal many of the problems above. The journey to healing can be slow, but hope is always possible. People experiencing any of the problems above should seek professional help, from a trauma specialist or the Blue Knot Foundation.

Adapted from: Ross and Halpern (2009) “Trauma model therapy, a treatment approach for trauma, dissociation and complex comorbidity”, TX:Manitou Communications Inc.

Working Effectively with Trauma- Guidelines for Clinicians

As stated in the previous blog, a purely talk-based approach is not sufficient for most complex trauma patients, and indeed may further traumatize them(Van Der Kolk, 2015).

So if we cant do “treatment as usual”, what options do we have? To begin, we need to widen our skill base to include other types of therapy(Blue Knot Foundation 2019).

Remember, there is no magic treatment approach that will help everyone. For example there is growing evidence for EMDR for complex trauma and C-PTSD, but Bessel Van Der Kolk suggests this may be best used with people who have single incident trauma- not complex trauma. I have found it useful to include practices such as trauma sensitive yoga, especially where there is significant dissociation, however where clients are body- phobic this may be inadvertently re-traumatising . Nonetheless it is useful for clinicians to have a wide skill set to complement existing skills, for example Sensorimotor psychotherapy or somatic experiencing training, art therapy training, equine therapy training, EMDR, the Conversational Model, Trauma Sensitive yoga training, child and adolescent trauma therapy, family therapy, neuroscience etc. I would suggest adding to your skills gradually so you aren’t putting too much pressure on yourself to be the ” perfect” therapist.

How we “show up” in therapy is also important. The Blue Knot guidelines (2012) suggest following 5 threads from Shapiro, which I compare with similar ideas and practices from Gestalt Therapy and Acceptance and Commitment therapy(ACT) Mindfulness practices.

  1. Presence (defined as `getting into the here-and-now experience of body, affect, and thought’) In Gestalt this is described as the phenomenological attitude, for others this is known as a state of Mindfulness.
  2. Dual awareness (`holding the trauma in mind, while maintaining focus in the current time and place’) In Gestalt this is known as “bracketing”. In ACT this is known as “holding lightly” “being present” and “observing self”
  3. Affect (emotion) while in relationship (`It’s not that the affect is discharged, though it might be. It’s that it’s felt and not avoided [ie within the `window of tolerance’] then witnessed and survived, then transformed into a memory, and no longer a developmental catastrophe’) In Gestalt this is known as “entering the experiential world of the client”, done with patience, reverence and respect. In Mindfulness, this is called “rolling out the welcome mat” for emotions.
  4. Relationship with self and other Patients gain tolerance and acceptance of their own affect and history and the capacity for relating to others through having a relational experience of tolerance and acceptance in the room. In  ACT, this is about acceptance of what is, and commitment to taking action to build a life enriched by values. However, where the patient has disorganised attachment, it is important to seek supervision regarding how to proceed, as attachment also creates terror or anger and may sabotage therapy. Handling disorganized attachment is much more complex, and the Janina Fisher website has many resources on this subject. Also, the principles of Richard Schwartz on Inner Family Systems are useful to bring into relational work with people suffering complex trauma.
  5. Making meaning of the traumatic events (`often accompanied by anger, then grief, then great relief’)227       In Gestalt we make meaning together. We believe that grief and shame need to be witnessed for healing to occur. In ACT Mindfulness we try to profoundly accept that suffering is part of the process of living. Rather than avoid, we make contact with suffering, grief or shame, with support from the therapist We are not trying to get rid of suffering, but rather to change our relationship with it.

Locating these 5 `threads’ helps to orient to what is now a rich, expanding but also contrasting landscape of therapy modalities for working with complex trauma. Again, the strengths, resources and preferences of the patient need to be included, including their age and cultural requirements. Children who have limited words for what they are experiencing can be supported via the generosity of the free resources on the Australian Childhood Foundation website. I have found some of their resources useful when working with adults.

  1. I would add 8 further dimensions to those above when working with people with complex trauma, starting with awareness of the role of culture, gender and other forms of diversity, presence or absence of external supports, and inclusion or exclusion of family in the work, including acknowledgement of intergenerational trauma.
  2.  The work should be phased- with stability and safety as phase one, as per the International Society for the Study of Trauma and Dissociation (ISSTD) guidelines. However, if sessions are limited in number by funding or other issues, focus on safety and stabilization, and liaise with other experts eg community psych support services. Don’t try and do too much or do the work on your own.
  3. Management of risk should be done carefully, sensitively and thoroughly, and decisions about how to reduce risk be made with the patient where possible. I will write more on this later this year, as it is a painful truth that many patients presenting to health services with risk have reported they are shamed or treated badly by those services (Benjamin 2019).  As much as possible, patients need to be empowered to make choices that best support them when they feel unsafe or have high risk behaviours.
  4. It is important that the power base of the work is not “one-up one-down”. Clinician should never consider that they are “expert”, instead a collaborative, respective and co-equal approach is best (Benjamin, 2019). Therapists should be committed to lifelong learning including from consumer forums online as the field is rapidly and significantly changing in multiple fields eg the neuroscience of attachment.
  5.  Unlike other types of psychotherapy, clinicians in this field should be careful not to foster attachment to them too soon by the patient (Fisher 2017). Work is enhanced by adopting a curious, respectful and collaborative stance with the patient about their parts, and by teaching the patient to distinguish between triggers which reprise past trauma or trauma happening now. This is best done gradually and by working with all parts of the fragmented self of the patient with equal care and consideration. Psychoeducation and Mindfulness training should be foundational, and teaching the patient how to manage strong or uncomfortable emotions is essential.
  6. Clinician should learn to be grounded, centred, and calm, no matter what is happening with the patient in the room (Schore, 2012). Our state helps to model, anchor, settle and soothe patients, to give them a beginning experience of secure attachment (if or as much as they can tolerate.) Eventually the work will lead patients to secure attachment with themselves, built on a foundation of awareness, compassion and trust. This in turn will change the way they relate to others and the world.
  7. This implies that all therapists who work with traumatized patients have undertaken their own psychotherapy previously, so that they can be the solid ground from which to do the work. Personal therapy offers many advantages to the clinician including awareness of their own character strategies and defences, and how this affects their way of working, e.g. what things are avoided in the room.
  8. Clinicians should be reliable and consistent, and with good written terms and conditions including boundaries, and explaining the limitations of therapy. Annual leave and the like should be advised beforehand, and time allocated to process the effects of the clinician’s absence on all parts of the patient’s inner family system.
  9. Clinicians who work with complex trauma must have regular supervision, by someone with recent experience and additional training in this field. This is to help prevent burnout or vicarious traumatization, and also to ensure that practices are up to date.

I am hoping these guidelines are helpful and welcome your feedback and comments on this series of blogs offering guidelines for clinicians working with complex trauma.