Healing Traumatised Parts

Healing is not all sweetness and light; or rather, the road to getting there is can be fraught with tribulations, pain, rawness or anxiety, and injury worst of all -from ourselves. Most people have parts that want help, while other parts want to run away, fight the therapist or deny the issues.

When we look at the legacy of past complex experiences including surviving many different kinds of trauma or neglect, we see all the things we have carried to this point in our lives. Healing is not a simple process. We may need to heal different parts of us that feel anger, hurt, grief, issues related to addiction, relationship or intergenerational unfairness issues, disowning of parts of ourselves including the body, certain emotions or thoughts; faulty beliefs that feel true such as the belief that we do not deserve love or belonging.

Then there are patterns or habits to heal- especially those that make us refuse to accept-or even perceive- the reality of life, or make us  live a life based on fantasy, ideals, perfectionism, or the need to control ourselves or others.  These sorts of patterns also have a sneaky way of making us very self critical and hard on ourselves, or makes it hard to get over even small upsets.

Through many years of working with people who want to heal, I would say that learning to accept and love all the parts of ourselves is central to healing.  Yet often it seems that people surviving trauma have an unspoken agreement with themselves that they will be kinder to themselves and look after themselves better only when and if they are healed. Paradoxically people continue to mistreat or neglect, criticise, drive themselves too hard , exhaust or hurt themselves in other ways, doing the things they have always done, instead of doing the opposite- loving, accepting and honouring themselves.

The truth is, if we want healing, we  need to first address the old patterns of how we relate to different parts inside.  This requires first finding a calm state then learning to be mindful or cultivate a dual awareness of what is going on inside- to unblend with old patterns and procedural ways of being in the world.

Here is a worksheet I used for trauma group sessions a few years ago which participants found useful. It is adapted from the ideas of Babette Rothschild, Peter Levine, Kathy Steele, Janina Fisher and many others.

Finding a good trauma-informed therapist or group to belong to and practice these skills is really important. Usually a safe place or a safe state is needed. Since the trauma was caused by relationships, relationships of a better kind are needed to heal the trauma. Remember. healing trauma is possible.

 

 

 

Compassion as the Core of Healing

What is Compassion?

A simple definition of compassion: Deep awareness of the suffering of self or others, and the ability to be with that suffering, with profound acceptance, and without pushing it away, labelling it or judging it.

Here’s another:

According to Pema Chodron (a Buddhist nun), “When we practice compassion, we can expect to experience the fear of our pain. Compassion practice is daring. It involves learning to relax and allow ourselves to move gently toward what scares us”. 

Chodron teaches that we must be honest and forgiving about when and how we shut down. In compassion, we draw from the wholeness of our experience- our suffering and empathy, as well as our cruelty and terror. It has to be this way. Compassion is not a relationship between the healer and the wounded. It’s a relationship between equal parts of ourselves. Only when we know our own darkness can we be present with the darkness of others. Compassion becomes real when we recognise our shared humanity. 

Reflection: To know our own darkness, is to allow ourselves to know the truth that we are human, fragile or imperfect. Yet many people with complex past experiences struggle to be compassionate with themselves. There may be a very harsh inner critic or a persecutory part that is quite relentless. Do you have an inner critic? If so, what are the most common beliefs or statements from this part? Would your best friend agree with what this part is saying?

So how do we learn to be more compassionate? It helps if we break compassion down into a behaviour or an action, so that we can get to know it as an experience, rather than just an idea which we might get around to “some day”.  Think of compassion as an action word. What attitudes and behaviours would go with compassion, what does it look like in action? For example, being compassionate to yourself could mean:

  • listening to your body
  • learning to be present
  • accepting or allowing difficult emotions or pain calmly
  • learning to accept life on life’s terms if this is the best or only option
  • being honest and gentle with vulnerabilities
  • healing old patterns that are problematic
  • finding balance
  • allowing yourself to heal
  • slowing down
  • letting go of excessive shame or guilt
  • being humble and soft instead of arrogant or rigid
  • allowing your voice to be heard
  • putting boundaries on those who dishonour you
  • backing yourself instead of undermining yourself
  • communicating frequently with inner parts to soothe and settle the system
  • giving yourself and others kindness instead of harsh judgements/criticism
  • all of the above
  • other things not listed?

Looking at the list above, which aspects of compassion stand out the most and which ones do you long for ? I look forward to hearing your thoughts and ideas on this.

Healing Shame and Self Criticism

Whenever we begin to heal trauma and dissociation, shame always shows up.

Shame is the feeling that there is something wrong with us as a person, (different from guilt which is about our behaviour). Shame is a complex emotion, because it contains a feeling of being defective, and has with it a desire for concealment. 

Rarely do we identify shame directly. Instead we use code words such as:

  • Inadequate

  • Weak

  • Stupid

  • Boring

  • Disgusting

  • Repugnant

  • Toxic

  • Loathsome

  • Unworthy

  • Unentitled

  • Exposed

  • Transparent

  • Naked

  • Burden

  • Bother

Shame is typically pre-verbal, non-verbal, and automatic.

Common Immediate Responses to Shame: 

  • Numb
  • Blank
  • Empty
  • Can’t speak
  • Withdrawal/Flight
  • Dissociation
  • Attack- self or others
  • Rationalizing
  • Grandiosity
  • Collapse/Submit

Shame-Based Behaviours

  • Negative attitudes about self are treated as a fact
  • Have to be right all the time, defensive
  • Choice of words expresses disrespect or extreme harshness toward self
  • Hiding from exposure
  • With exposure, blushing or pale, quiet, small, not wanting to be seen, wanting to run away
  • People may describe it as “embarrassment”
  • Self-conscious and apologetic
  • Loss of eye contact and looking away (there are cultural exceptions)

What Activates Shame? 

  • Commencing in a new situation eg therapy
  • Being asked to do something suddenly
  • Being asked to do something beyond your capacity, eg a young child being expected to take care of adults
  • Being vulnerable or open when others are not
  • Sarcasm, attack, criticism, contempt
  • Being ignored, neglected, invisible, treated as insignificant
  • Powerlessness/not valued by others
  • Betrayal, abandonment or rejection
  • Attack or threat to your dignity or personhood
  • Becoming aware of social/cultural differences eg our family is poor
  • Comparisons to others eg everyone is married with children, but I’m still living with my parents
  • Receiving the message we are “too much” or “not enough”
  • Cold distant or humiliating response from others
  • Overreaction by others for trivial incidents eg spilt milk causes parental rage when young, makes us confused and we think there is something wrong with us
  • Growing up in an environment of shamed or shaming adults
  • We can also be shamed for not belonging, being different, for wanting or not wanting something. 

Healing Shame 

The good news is that due to neuroplasticity, we don’t have to live with intense shame forever. But how do we do this? Simply telling a person not to have shame may be a form of pushing the person away, which may intensify their shame, or accidentally produce “shame about shame”. This is something trauma therapists are hopefully becoming more aware of!

Since shame makes us want to hide away and isolates us from others, the antidote to shame is relational- warm acceptance and connection to others. By building relationships where the shame can be named and held, not as something toxic, but as something worthy of Mindful compassion and acceptance, we begin to change our relationship to shame and it loses its hold on us.

Shame can eventually become “just another emotion”, not “a fact” about who we are. When we get to this place, transformation and deep healing will follow.

 

 

 

International Trauma Conference in Melbourne, 2016

I haven’t had time to attend the whole thing, but it is amazing to see over 2000 delegates here in Melbourne for the conference this week. As usual Pat Ogden, Stephen Porges, and Allan Schore are here, and inspiring.  This year I have enjoyed Martin Teicher, Dan Siegal and others. Martin shares some wonderful scientific research results on the aftermath of trauma, you can find it on Google, WordPress, by adding his name.

Trauma is still the “elephant in the room” in terms of public health policy, and is still missing from public discussions except in a very limited way. The survivor is still all too often blamed (via the rigid DSM criteria which is not evidence based, if not the Catholic church, the defence forces, etc), for their symptoms. Actually, I believe survivors are incredibly brave, tenacious and valiant to have survived, especially when we review the outcomes from the ACES study in the USA.

This study as reported by Martin shows the significant long term effects of adverse childhood experiences. Basically the higher the number of adverse experiences, the more likely the person is to have not just emotional and cognitive consequences, but also physical consequences including changes right down to the genetic level, heart attacks, addictions etc.

So this week I really feel inspired to acknowledge and thank all the scientists, clinicians and others who have travelled from US, UK and Europe to be here for the Conference. A special nod to Sue Carter re the importance of oxytocin in love and bonding. And to Dan Hughes for bringing such warmth and humour to this difficult topic.

Their long labours  research and experience in working with trauma now give us a legitimate voice to begin a more sophisticated and compassionate public discussion about how we view and treat trauma survivors. The Royal Commission into Institutional Abuse misses the great majority of abuse which occurs at the hands of family.

The science also enables us to confidently say that trauma can be healed. And finally, perhaps, we can now stop judging and blaming victims, and work together to ensure they are honoured and supported throughout the healing process.

 

 

Working Gently with Embodied Awareness

 Most modern trauma psychotherapy treatments aim to include the body in some way in the work of healing trauma.

Yet many patients with complex trauma conditions have an understandable phobia about noticing  their body, or are numb or dissociated from their body. Body awareness often triggers a danger response or feels unsafe in some way.

For example, health professionals may start by inviting patients to practice mindfulness, eg with the breath, only to find that simply focusing on the breath has inadvertently triggered a fight/ flight/ freeze/ dissociation or hypervigilance response. So it is essential to approach any body work with great caution, respect, gentleness and preparation!

Preferably, the health professional will  undertake additional training in somatic modality  such as sensorimotor psychotherapy or somatic experiencing before attempting any such work, and will also be aware of their own transference and countertransference through their own in depth personal psychotherapy experience. I add this caution as untold harm is possible via unaware or unskilled interventions when working with the body. Please do not attempt this unless you are professionally prepared!

How do we work safely with the body? There is a four step process that can help to set this up. This week we will discuss step one, which is setting the stage properly, to create the optimal setting before beginning any body work.

According to Dr. Andy Harkin, a Sensorimotor Psychotherapist from the UK now living in Australia, we need to be clear with the patient HOW we are working with the body as well as WHY. He talks about this on youtube

So, ideally, we could start with Psychoeducation, right? Hmm, not so fast! What if the patient is not ready for this? Patients at the more complex end of the trauma spectrum will probably need preparation, prior to the apparently simple step of psychoeducation.

There is no point trying to educate if a person is in sympathetic nervous system hyperarousal. Their frontal lobes are effectively “offline” for survival reasons, so the capacity to absorb information is greatly reduced, and if they are distressed enough they will quite probably misperceive what is being said as their system is primed to detect danger to help them survive. Ideally, education is not offered until the patient is as calm and settled as possible.

So first step, ensure that you the therapist are calm and grounded, quiet and still, and let your nervous system, body and voice help the patient settle into a calmer state. Explain what you are doing simply. Your limbic system and mirror cells really can help, as calmness is contagious!

At this stage, you are not aiming for the person to be totally relaxed, nor are you beginning to talk about any trauma. Instead, you are just aiming to practice being present with the patient in a way that offers a small amount of relief from SNS symptoms if they are in hyperarousal. A calm gentle presence, some quiet reassuring words, and just sitting.

For some patients, you can invite and co-create small experiments to foster collaboration in helping the room to feel calmer, for example adjusting blinds or reducing lighting a little, adjusting the position or distance of the chairs, adjusting how you are both facing in relation to each other.

It is important to focus on CALMNESS instead of SAFETY. Saying the word “safety” can often trigger hypervigilance and hyperarousal in complex trauma patients.

Some patients feel calmer if they have something to squeeze or hold, a cushion or soft fabric. Some people need to stand up to feel calmer, this seems to be true especially where the spine is collapsed or the posture is slumped. Also, orienting to the room and then naming the date and time can help. Ask the patient to simply notice “calmer” or “less calm” inside the room. Use hand signals not words to communicate regarding this.

Avoid the impulse to DO something such as talking incessantly or writing out a prescription and instead practice just BEING with the patient in a calm and respectful manner.

Sometimes, depending on the patient and situation, being light and playful can also help. Depending on the patient, sometimes I scrunch up and toss paper balls, do side by side colouring in, roll or push large gym balls, play peekaboo, squeeze playdough, ask them to pass something in a funny voice etc.

You may spend hours, weeks or months like this with the patient, helping them to develop a felt sense of calmness and tranquillity in the room, helping them learn to soothe and settle, and gently explaining why this is the foundation for the work of healing. This is body work, as you are helping the patients body, brain and nervous system get used to the unfamiliar state of being in the window of tolerance.

As they begin to settle, you will be able to offer more in the way of psychoeducation. Although you may have very intelligent and sophisticated patients, it is important that the learning material is simplified initially. In my experience, even the word Amygdala can cause panic!

Choose your learning materials- visual, tactile, olfactory, toys and other objects- carefully and allow time and opportunity to absorb the information before you give more. Visual aids or videos are useful for this, for example the 3D Brain App. You can make your own aids or purchase from Janina Fisher and many other international sources.  For the patient with hyperarousal, slow is always better, and you must be able to hold that space and repeatedly explain to the patient why you cannot rush, especially healing!

Now you are ready to explain in detail how trauma affects the body systems and processes, in a way that is appropriate for your patient.  You can also begin to educate about the importance of learning mindfulness at this stage and perhaps now begin to notice mindfully together the experience of being calmer.

To strengthen the patient’s commitment to the work of healing, it makes sense that you practice what you are teaching including developing capacity for interoception, awareness of subtle changes in your own body, and being able to develop a wide vocabulary for describing what you notice. The therapist’s capacity to be embodied greatly enhances the possibility that the patient will eventually learn something more about embodiment.

Next, and before approaching any work with the body, it is important to negotiate conscious permission giving from the person to do the work of healing. This will require negotiation with all the parts if structural dissociation or DID are present. Respect for the patient and their parts is critical at this point. Do not start any body work without permission being established. Do not ignore parts who are undecided. Do not rush this step! We will discuss the art and science embedded in the process of permission giving as part of the forthcoming trainings to be offered next year for health professionals.

The above approach is based on the work of prominent trauma leaders as described elsewhere on this site, and my own experiences as a practitioner working with complex trauma, dissociation and DID. Your views and comments about this post are welcome.

 

 

 

 

 

 

 

 

 

Understanding high risk behaviours

Understanding Self Harm, Addictions or Repeated Suicide behaviours in Complex Trauma

By Janina Fisher, Adapted by Claire Hudson-McAuley 2015,

As we know from the work of Bessel van der Kolk, Onno van der Hart, Bruce Perry, and the ACES study, childhood trauma dramatically interferes with the body’s ability to function and regulate itself mentally, emotionally and somatically.

The profound impact of trauma alters perception, thinking, tolerance of uncomfortable emotions, basic bodily functions such as digestion and respiration, hormonal and metabolic processes,  immune function, and the expression of genes. Relationships with others and self, trust, the ability to function in everyday life, and even the ability to learn are compromised.

Psychological development is delayed or distorted, and identity formation proceeds along the “fault lines” that result from dissociative defences and compartmentalization. Is it then any wonder that adult survivors of trauma become so remarkably adept at inventing compensatory strategies aimed at survival and  self-regulation long before they enter the doors of our offices, hospitals, or clinics?

 

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DIY Healing Trauma

Settling skills

There are many ways to begin to heal trauma. Before we contact any aspect of trauma, we start by learning how to manage uncomfortable emotions. Safety and stabilization, the ability to tolerate distress and to return also from a state of numbness or dissociation, are all important foundational skills to begin the process of healing trauma.

Attached is a handout I sometimes use with some basic tools and skills. I would be interested in your feedback

How the Health System Harms Trauma Patients

Trauma treatment is a field which has evolved perhaps more radically than any other field of medicine in the last 20 years, but is still harming patients.

Driven by many breakthroughs in neuroscience we have a better understanding of how the brain as a whole works, including the effects of long term trauma and mis-attunement on the brain and nervous system, the discovery of mirror cells, the importance of nervous system and emotional regulation to prevent re-traumatisation during therapy, the significance of the therapeutic alliance, and the astonishing range of survival strategies and structural dissociations which allow humans to survive otherwise impossible ordeals. All this on top of the incredible discovery of neuroplasticity which now offers the potential for a cure to what were previously believed untreatable trauma symptoms.

New knowledge however, takes a long time to spread. For example, some health professionals  still prescribe Betadine for wounds, even though we have known since the eighties that it actually irritates skin tissue and impairs healing!

Likewise, I’ve noticed that a good number of health professionals seem almost entirely ignorant of these last two decades of scientific advances in understanding trauma, still working conceptually within the old, “biological” model. The biological model, favoured by drug companies, is where one simply tips in some chemical to “sweeten” a brain that seems a little sour after trauma. Drugs, drugs, drugs. Take some more drugs, please.

This seems to be the default position today. If, after many months of trialling drugs you say don’t want more drugs, and you want to try and learn to manage the emotional distress yourself, you are somehow being a difficult patient! In fact, one of the primary drugs used for trauma patients, Seroquel, was originally marketed as Quietipine- the drug to quieten troublesome patients! So patients are apparently supposed to shut up and take their medicine.

This despite the fact that international expert bodies such as ISSTD do not recommend drugs as first line treatment for complex trauma and dissociation.

“By the way, we are going to treat you like a wilful, wayward child, not like an adult who suffers from long term serious symptoms of trauma. “Putting in boundaries” becomes an excuse to adopt a punishing stance which blames you for your trauma symptoms.” Many studies now show that the very places that people go to for help often retraumatise them or leave them feeling belittled and ashamed. 

I suspect that for evidence-based practice to be possible, there has to be an open mind, space for new learning. In a way, we have to be innocent and adopt what the Buddhists call “beginners mind”. When any health professional holds the position of being “expert”, it is so much harder to learn, let alone take in the huge amount of new scientific knowledge that allows us to treat trauma safely and effectively.

As the ASCA guidelines for trauma sensitive service delivery (2012) explain, it is clear that many times, the patient, who goes to hospital or other health services for help, is actually further traumatised and re-traumatised by the very system that should be helping. I believe that unless health professionals inform themselves and adopt more evidence based practice, this will never change.

Since I wrote this blog in 2014, ASCA, now called the Blue Knot Foundation, has published another comprehensive update on best practice in the treatment of  complex trauma, in 2019 (Kezelman & Stavropolous ). In June 2020 as I review this blog, I believe that today even more than before it is an ethical imperative for all health professionals to be trauma informed, especially with the world in the crisis state it is now in.

 

Shame as teacher

Long term stress and trauma can leave us full of shame about our vulnerability, frailty, humanity or need. Shame tends to freeze us, numb and disconnect us from others, or make us supress parts of ourselves. But could there be a positive side to shame?

Shame researcher Brenee Brown talks about the benefits of owning our shame and vulnerability- you can see her on  TED talks on utube. Her message, powerfully delivered, is that shame numbs us. But we can’t selectively numb. If we numb  our shame, we also numb  joy and pleasure. Our life becomes driven by “shoulds”, the relentless search for perfection, and the denial of our limitations. So recognising and bringing compassion to our shame is essential if we want to relax its grip on us.

There are many ways to reduce shame, and Mindful living is one place to start. If we can hold the truth of our lives- all that is working and not working, beautiful and ugly, with love and compassion, then the bindings of shame start to loosen.

How do we do this? How do we learn to soften, soothe and allow the relationship with ourselves to become kind and nurturing? I will write about this more in the coming weeks. In the meantime, I look forward to your feedback and comments.