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.

 

 

 

Toward Better Care in Mental Health

Patients who have experienced complex (childhood) trauma or C-PTSD are frequently stigmatized by healthcare institutions, and ignored, misdiagnosed or worse if they attend clinics or hospitals (Benjamin, 2019). The very services they turn to for help often to treat them with disregard, disrespect, or contempt, especially if there are self-harm or suicidal symptoms, potentially re-enacting or repeating the original trauma which was relational. Often, patients report being treated like wayward adolescents, ignored, disrespected or at worst rendered powerless. Like a client of mine who felt suicidal and sought admission to protect herself from her own impulses, but then was discharged from hospital abruptly when she attempted suicide on the ward, with no clear safety plan.

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

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.

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 Trauma Safely

There are plenty of people – both health professionals and the people seeking help- who still believe that the way to heal trauma is to talk about it -in detail. Nothing could be more dangerous! Many people say they feel worse after such sessions- for days, weeks or years! Sadly, this approach puts some people off therapy for life.

Why is this so? Because talking about trauma- even thinking about or saying the word “trauma”- can activate us exactly like the original trauma. Science now confirms this. Our brain, nervous system and procedural body memories are activated exactly like the original situation. This can be every bit as distressing, or even more distressing than the original trauma.

So to heal trauma safely, we need to create some resources first, some “scaffolding” to allow the processing of trauma to be done without accidentally retraumatising the person seeking help. Pat Ogden suggests that we focus on resources that bring the person back into the Window of Tolerance (a calm and settled state). Peter Levine suggests further that we focus on working with the patient to find a strength or competency within the body or mind which makes it possible to avoid engaging in reactive responses. Peter calls this Pendulation.

For myself, I am developing a model called the 5Brain model where we connect to another calm, well regulated person and bring ourselves into the present moment to help settle our system. If another person is not available, we can establish a “calm and resourcing place” to go to mentally, which includes elements that settle and soothe. Since the type of trauma I work with is most often relationally based, it makes sense to include support and “scaffolding” from others.

At first, having a compassionate and attentive human presence may create grief or upset in the person seeking treatment, as they realise more fully how alone they have been up to this point. The aftermath of trauma can be a sense that we are “different” and do not belong, or are not valued. Knowing that there is at least one person on the planet who really “gets” us, in small slivers of experience, means that we can begin to relax. Healing therefore, is stimulated as a result of  relationship- with others and ourselves- that helps compassionate  self study .

I welcome your feedback on this blog.

 

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.