Elyn is an inspiring person who has led a full and rich life despite a diagnosis schizophrenia. She talks heartbreakingly about her experiences in healthcare, and how therapy, medication, work and connection to others has aided her recovery.
Healing is possible!
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.
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.
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.
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.
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:
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.
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
To escape the co-dependence pattern I suggest that you start by learning positive skills and boundaries for yourself and others as illustrated below.
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 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.
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.
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.
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.
Patients are effectively silenced with strong medications, ECT or other treatments which lack substantive evidence base, such as admission to hospital for long periods of time which has been shown to decrease positive outcomes in complex trauma( Fisher et al, 2015). While working as a nurse in the past I have observed many patients arriving at the hospital with large plastic bags filled with medication on admission. Instead of asking “what happened to you” as we should, many health professionals only ask ” do you have any risks?” or “do you want some seroquel?” There is little understanding of the long term impact of adverse childhood experiences(ACEs), the effectiveness or ineffectiveness of medications, the importance of a collaborative approach, or even the neuroscience of trauma and attachment despite decades of research.
There is even less recognition of the various dissociative conditions that accompany complex trauma, ranging from “structural dissociation” (Steele et al) to depersonalisation, derealization or DID. ( Kezelman & Stavropoulos, 2019)
Why is this? Well, one of the reasons is that the practice of medicine is supposed to be evidence based- that is- relying on scientific studies that are well designed and free from bias, to inform best practice. This means that as the science evolves, ways of treating conditions should evolve too. However, in Australia the Diagnostic and Statistical Manual (DSM) is a widely relied upon taxonomy of mental health conditions with descriptions. In the medical world, there is growing concern about DSM, and both national and international research funding bodies are no longer supporting research proposals linked to DSM criteria as they are not valid or reliable(Benjamin, 2019).
DSM categories and descriptions are simply based on the opinions of psychiatrists in the US, who do not always listen to the opinion of subject matter experts. Concerningly, it has been reported in the BMJ and by many others that up to 75% of these contributors to the DSM are funded directly or indirectly by drug companies (Moynihan, 2015). Further, the drug companies have a publication bias which ignores drug trials which don’t further their marketing of drugs! (Wampold et. al, 2013) Drugs may also be declared safe for long term use after a trial of only six weeks. The editor of the British Medical Journal resigned in protest at this publication bias some years ago, but as yet no government will curtail Big Pharma as they risk losing their substantial political donations. Moynihan points out that in 2015, drug companies sponsored 30,000 “education events”, and his research shows that drug companies are ever lowering thresholds for the definition of many diseases to sell more product, for example ADHD medication.
DSM classifications are widely used by government, health insurance funds, and health professionals to communicate information about patients. This framework favours medication as the promary and often only treatment recommended for many conditions that are in fact the sequelae of complex trauma.
Patients are stigmatised by labels like Borderline Personality Disorder, and this contributes to the problem of creating a health care system with appropriate care and treatment for people with complex trauma symptoms. The labels imply that the problem is caused by or located purely in the patient, instead of co-locating the problem within the family and societal system. Many concerned doctors such as Bessel Van Der Kolk have written about this distortion of the therapeutic lens, and Bessel has tried strenuously to influence the medical DSM panels in their description and understanding of trauma. However, the panels have so far rejected the evidence and maintain DSM categories which are pejorative and unhelpful for best practice in treatment of complex trauma.
Very few organisations have properly or even partially implemented the Guidelines for Trauma Sensitive and Trauma Informed Service Delivery published in 2012 by the Blue Knot Foundation ( Formerly ASCA ), and revised in 2019.
Also using drugs as first line treatment means that patients are never taught the skills and attitudes necessary to manage uncomfortable emotions like anxiety and depression, to manage flashbacks or panic attacks, or to deal with the shame, fragmentation and loneliness of their condition. Over time, they may become more dependent on medication and less self- trusting and self-resourcing.
Yet due to funding costs in hospitals and lack of real support for staff, many clinicians are under so much pressure that they can scarcely listen to, let alone respond to in a thoughtful, respectful and collaborative way, to the patients who are presenting for help. Literally, their stress levels are so high their brains are “off line” a lot of the time. This often creates a massive over-response to and focus on “risk” or “safety” rather than care, choice and collaboration.
To be fair, clinicians are generally taught little about complex trauma during their training, but there is such a negative response to symptoms such as self harm that much leadership, reform and education will be needed before mainstream services change (Benjamin, 2019). We also need to be aware of ethical boundaries that prescribe how organisations, governments and individual clinicians should best respond to outside attempts to influence, including gifts, overseas travel, education, wine, food, gratuities and other incentives from drug companies, and seek greater transparency in research on drugs with supposed efficacy. Some work has been done on this in Australia but not enough in my opinion.
In the meantime, those of us who work closely with individuals with complex trauma must do what we can to educate and inspire change, where possible in our professional networks or groups, in addition to educating our clients. This website is part of my desire to support change!
In the next blog, I will turn to what Clinicians can do to work more effectively with patients suffering from complex trauma.
Clinician Guidelines for Working with Complex Trauma
Part 1
To work effectively with complex trauma, we must challenge habitual ways of doing therapy, unlearning old habits and making room for new ones. In this three part blog I explore why treatments and approaches have changed, some system problems that prevent effective treatment, suggest some ways in which working with trauma is different from traditional therapy and invite the clinician to cultivate the attitudes and qualities which are most helpful, and reflect current best practice in the field. I mention a number of world leaders in the field for those who wish to know more.
What is Complex Trauma?
The term complex trauma or C-PTSD has come to mean the type of trauma which is not a one-off event, and is relational. Complex trauma can include mental, physical or emotional cruelty or abuse, witnessing abuse done to others, or neglect. It can also include adverse experiences such as the loss of a significant caregiver eg through divorce or death.
The aftermath of this type of trauma shows up in relationships, where it is more difficult to trust others or ourselves. Survivors may feel too little or too much, be fragmented or compartmentalized, have difficulties with resilience, or have a cruel inner critic. They may carry intense shame or a sense of being unlovable for which there appears no antidote. This and a host of other problems of loving and living, shadow the lives of people who have experienced complex trauma. However, we also know that healing is possible.
Why has Trauma Treatment Changed?
We know a lot more now. For example, the Adverse Childhood Experiences Study (ACES) in the US is a longitudinal study of around 17,000 people, started in the eighties to help understand why some members of Kaiser Permanente health fund were obese. Researchers randomly picked ten criteria for the study. Unexpectedly, this study has since shown that the greater the number of adverse childhood experiences, the greater the risks of adverse sequelae- including physical, mental and emotional issues. Also, the signs and symptoms of adverse experiences may not show up for many years.
For more information, go to https://www.cdc.gov/violenceprevention/acestudy/
The ACES study tells us that people who have experienced complex trauma are more likely to have difficulty maintaining stable employment or stable relationships and are over represented among those who are admitted to hospital, attempt suicide or suffer from addictions.
Also, many branches of science have advanced massively in the last two decades. Fields including endocrinology and neuroscience are providing astonishing new facts about the brain and body which includes the discovery of neuroplasticity and a growing awareness of how stress harms the body.
Neuroplasticity is how we learn, and it is also the way the brain adapts to different environments to enable survival. Thanks to people like Schore and Siegal, we now know that how the brain works is shaped by the environment -especially our earliest experiences with people. Experience changes the brain, body, and emotions, and vice versa.
People with complex trauma show brain structure changes visible on scans, for example their amygdalas may be enlarged. Their nervous system is wired to be more sensitive to threat, harder to calm down or relax, or sometimes harder to get going. Stress hormones such as adrenaline are oversupplied, causing difficulties with sleep, gut and many other issues.
Steven Porge’s work tells us that when activated/anxious (in Sympathetic Nervous System arousal) we cannot listen properly, make good decisions, or digest the past. Therefore it is essential to help create a calm and settled state in the patient before we start any therapy.
Also, many survivors of childhood trauma carry implicit or procedural patterns, tendencies and memories in the body. These are not accessible via the prefrontal cortex (thinking brain), eg wordless terror, shame or disgust that is pre-verbal- so doing talk therapy alone is of limited usefulness.
There is higher risk of mental health issues such as depression and anxiety, addictions, psychosis, paranoia or OCD, difficulty regulating emotions, and more risk of physical health issues such as obesity or other food issues, sleep disturbances, poor self-care, chronic pain issues, sexually transmitted diseases, heart attacks and immune system disorders among other consequences.
Clinicians who are untrained in complex trauma may try their best to treat the presenting symptoms while missing the underlying cause. In a recent report in the Neuropsychotherapist, they report on a study showing childhood trauma is often missed or not enquired about at all by treating clinicians.
Luckily, there is growing momentum in the world, from people like Lou Cozolino, Allan Schore, Bessel Van Der Kolk, David Wallin, Steven Porges, Pat Ogden, Janina Fisher, Martin Tiescher, Peter Rossouw and Dan Siegal. These are among the many new thought leaders that are inspiring change and illuminating the path for effective treatment for complex trauma. Interestingly, there is a limited role for medication in the new paradigm, as the biological approach is not effective on its own.
For example, Porge’s polyvagal theory has been widely adopted as part of the new understanding of how the nervous system is impacted by complex trauma, and what to do about this. His theory is, in my experience, extremely useful, as it explains and normalizes many common difficulties, and leads to many non- drug ways of treating distressed states.
Pioneers like Janina Fisher have adapted the work of Richard Schwarz (Inner Family Systems) to help work with the complexity of the individual who is fragmented in both subtle and obvious ways.
Based on research by the Blue Knot Foundation (formerly ASCA – see ASCA Guidelines for Trauma Informed and Trauma Sensitive Service Delivery, 2012), it is recommended that clinicians who work with complex trauma are trained in at least three different modalities, at least one of which is body oriented.
We who work in the field should also be aware of the broader societal issues that impact care and treatment for this already disadvantaged group, and be able to advocate for education and change where this is appropriate.
In summary, over the last two decades there has been a revolution in the treatment of complex trauma, moving away from traditional labels or approaches to encourage a more holistic framework which includes the body and relies less on talking or simply taking medication.
In the next blog I will write more about the system issues that impact effective treatment, and in the third and final blog for clinicians to start the year off I write about how to shape practices to be more consistent with world best practice in treating complex trauma.