Articles on childhood trauma and complex trauma psychotherapy. What therapists and patients can learn to alleviate and heal the symptoms of trauma.
This presentation was given live in Singapore at the National Counselling and Psychotherapy Conference on 21 November 2023.
This presentation took me months to plan. I was inspired to participate in the conference by my clients’ artwork.
Along the way, I heard this old song, “Anak” by Freddie Aguila, which inspired the experiential work and the poetry at the end.
Helbig-TRAUMA-SG-NOV2023-5Sia talks to Gabor Mate about her psychotherapeutic journey. In this interview, we get a sense of what psychotherapy for Sia is about, how it helps us transcend our fear of feeling difficult and often painful emotions.
Sia reveals her personal challenges suffering from somatic symptoms like Hashimoto’s, and addictions.
I enjoy this interview because it also reveals how Gabor is able to hold Sia’s emerging emotions throughout the dialogue.
Sia is an example of a kind of client who has had quite a bit of work done. The tendency is to “talk about” experiences rather than “being in” the experience. He tells us how he is not as interested in labelling and seeing phenomena as disorders, and his disdain for medical doctors who are not able to inquire about childhood.
By interrupting her deflection from points of painful feelings, giving space to emerging experiences he finds connection with her, and we also find connection with her watching the video. In a way, Gabor invites Sia to show her face and not hide it.
Interestingly, towards the end of their dialogue, as they thanked each other, Sia said, “…that almost made me cry, but that would hold up the interview…so… I kept the… for later…” This is possibly the replay of the trauma which she mentioned at the beginning of the video, where she recounted having cried as a young child and her caregivers were absent.
The DSM describes main feature of dissociation as a disruption of memory, consciousness and identity or perception. Dissociation is a protective mechanism. Human beings have at their disposal to survive traumatic events.
Abusive painful experiences and memories are put away into isolated compartments in the mind, and separated from regular memories.
Read also: Traumatic and Non-Traumatic Memories
Dissociation refers to a compartmentalization of experience: elements of an experience are not integrated into a unitary whole but are stored in isolated fragments (van der Hart et.al., 1998).
Exposed to trauma, the mind splits. The part of the brain that continues with the daily functioning of life (the left brain), and the emotional part of the self that holds the traumatic memories (the right brain) and its survival impulses of the moment of trauma becomes unintegrated with each other. This leaves the person with a split sense of self.
Experiencing a split sense of self can be disturbing. To notice the phenomenon as it happens is to gain agency.
The disruption of integration of the hemispheres of the brain leads to the experience of feeling something and “not making sense” of the feelings. The feelings come in the form of emotions, perceptions or physical pain.
The experience of not making sense of what one feels, can be disturbing. As human beings we need to make meaning and understand things about ourselves to feel safe. When such splitting occurs, the trauma survivor experiences blankness and confusion. This contributes to more insecurity. Oftentimes the need to make meaning results in thoughts that are paranoid in nature, intrusive and/or obsessive.
In therapy, clients are guided to 1. first identify the feelings and sensations that make no sense, 2. accept these feelings without making meaning. 3. observe the nature of thoughts that arise from attempt to make meaning, and 4. allowing these sensations to pass (through relaxation or somatic exercises). Each of these steps are tedious and challenging, needing full attention of both therapist and client. This is also solid mindfulness work. The result is the client gaining of agency of the self.
Splitting leaves the client fragmented into parts of personality. As different times the person’s right brain may trigger experience in him/herself a part that is raging and wants to fight or take revenge, a part that is terrified, a part that is ashamed, a part that is needy and/or a part that wants to run away. When these parts are traumatized, they feel out of control.
The left brain engages the other parts of the person that wants agency. These parts manage daily function, the part that is sociable, and the part that is responsible.
One can notice that splitting has occurred through phenomena like experiencing chronic inability to make decisions, continually relapsing into addictive behavior, having intrusive emotions that seem to arise out of nowhere, intrusive thoughts, shifts in mood or behavior, going numb, getting hyper-aroused, collapsing, feeling suicidal, hearing voices, loss of ability to connect with others, difficulty communicating, withdrawal from society, feelings in the body and somatic symptoms that are not based on medical logic.
Dissociative symptoms can be severe in some people to a point of rendering them incapacitated. Many individuals, however, experience dissociative symptoms, and are still able function and be successful in life.
Treatment of dissociative symptoms with therapy in functioning individuals is a measure to keep the person healthy and functioning. While we can cope with dissociative symptoms, these symptoms do not disappear on their own. Symptoms get worse with age, and are exacerbated by crises in life. This is why and how some seemingly functioning people experience sudden psychological breakdown.
It is clear that severe dissociative symptoms require professional attention. Less obvious or hidden signs of dissociation are worth noticing: 1. difficulties putting things together, not being able to remember conversations, forgetting appointments, or inability to recount coherently what happened in certain situations, 2. experience of doing things that does not seem to add up, like having sexual relationship with someone one finds unattractive, 3. having unexplained chronic pain or somatic symptoms, 4. chronic experience of stuck in life, 5. experience of identity confusion, 5. experience of self-harming or suicidal thoughts.
Therapy that focusses on mindful observation of these symptoms, its triggers and the trauma underlying lead to successful outcome in providing clients with agency over his/her life.
van der Hart, O., van der Kolk, B. A., & Boon, S. (1998). Treatment of dissociative disorders.
Psychological trauma is a person’s experience of one or more events that is too overwhelming for the person to emotionally, physically and intellectually react to, and integrate into his/her memory and sense of self. The experience is that of as sense of threat to life, integrity or sanity.
Traumatic events are varied. It can be one major event (as in the case of PTSD), a series of events or living conditions that persists. In traumatic events the person is vulnerable and loses sense of agency or control. Since vulnerability is the feeling, young children and babies are more prone to being traumatized than healthy adults.
Sufferers of PTSD tend to be more aware that they suffer from trauma than individuals who suffer developmental trauma or complex trauma.
Symptoms of trauma are often experienced as: irritability, depression, numbness, fogginess, lack of concentration, sleeping disorders, nervousness, panic disorder, chronic pain, addictions and addictive behavior, self-harm and suicidality, and eating disorders.
Trauma-focussed psychotherapists would check childhood experiences of individuals with these symptoms for sources of traumatic experiences.
It is not unusual for such clients who are not suffering PTSD but complex or developmental trauma to be baffled at the idea that they are manifesting symptoms of trauma, since these experiences are either forgotten, or because the memories in themselves are not recorded as traumatic.
Traumatic experiences that happen in infancy and early childhood lead to what is termed developmental trauma.
The younger the child, the more dependent they are on their caretakers for survival. Children get traumatized by neglect, separation and abandonment, exposure to domestic violence, parents fighting, witnessing violence, fearful caregiving, threats to them (meant or not), medical crises and accidents, death in the family, especially of parents and siblings.
Developmental trauma are more insidious than adult onset trauma because young children are not able to process the memories of the event(s) fully.
These memories are not integrated into learning experience, and remains out of awareness. As the child develops these memories become physiological and psychological symptoms.
Developmental Trauma presents itself also as generalized symptoms. Patients experience difficulties in areas like : 1) affect dys-regulation, 2) having a deep sense of self devaluation, 3) having difficulties forming relationships, and 4) dissociating from experiences.
Since memories of traumatic experiences are not adequately integrated, the body remembers the traumatic experiences without the brain understanding what they are about. Such memories of traumatic past experiences are called implicit memories, or memories without language.
Implicit memories are sensed. These are memories of the past. However, in the present, harmless events can happen that are similar in feeling to these traumatic past memories. The body reacts to these harmless present events like it did during the traumatic event. The individual is unaware of the past memory hijacking the present moment and gets triggered.
When the dust settles, the sufferer and those around him/her cannot understand how or why the person over-reacted to the present event in such an exaggerated manner.
We may all be familiar to getting triggered or witnessing someone being triggered. It can be disturbing and sometimes destructive.
Understanding that these triggered states of emotionality, fear or rage are rooted in past traumatic experiences can provide for some relief to all involved, because this condition can be treated with psychotherapy.
Psychotherapeutic treatment for trauma is an individual process. The condition of the patient and the extent of trauma first needs to be understood. Since traumatic experiences involve a deep sense of threat to life, the therapist needs to create a safe secure setting for the patient.
Trauma therapy can take months to years, depending on the condition of the patient and the trauma. There are five main phases involved:
Trauma therapy has its contra-indications. Patients can get re-traumatized if the groundwork of phases 1 and 2 are not adequate. The building of the therapist-client working alliance is thus very important to ensure safe, effective trauma treatment.
EMDR is a form of psychotherapy originally designed for trauma therapy. EMDR provides a here-and-now stimulus as the client recounts his/her traumatic memories. Tapping or eye movements keeps the client in the present and in the observer position. This keeps the client stable, so that he/she can remember stressful experiences without being re-traumatized.
EMDR is very much a relational-therapy application which I find very useful for integrating into my work.
EMDR is founded by Francine Shapiro. Here are 2 lectures of EMDR by Shapiro herself.
About Shapiro’s Way with EMDR
History and research history on EMDR
EMDR process has a structure. The actual procedure administered is unique to each individual. The therapist, during the session, has to remain focus on the phenomenology of the patient. Keep in mind that simply following the steps alone is not therapy.
Stabilization of the current situation of the client is important. The client is also prepared internally for the exercise. e.g. the client is asked to use a stop signal if he/she feels too uncomfortable. The client also gets to describe a safe place. In other words, the client is asked to consider the resources he/she has.
Estimation of the degree of severity of the experience. The client is ask to rate the degree of feeling felt at the moment about an event. The client is asked to describe and rate a negative aspect of the event (e.g. feelings of fear or guilt). The client is also asked to describe and rate a positive outcome of the event (e.g. feeling of freedom from guilt).
The client is asked to estimate how strong the feelings of stress at the moment is.
The client is asked to describe how he/she feels in the body.
Pre-processing step: to ask the client to relax and recount the event. Allowing the client to creatively enter into the scene. The therapists begins to lightly tap on the client’s wrists or knees, or guides the client with eye-movements, and encourages the client to describe the situation(s) as they arise to consciousness.
The weaving in of the here-and-now situation with past situation. The client gets to see the traumatic experience as a more mature person (as opposed to a child when he/she suffered a trauma). The client also gets to view the situation from a vantage point of a safer present.
Re-evaluation of the feelings of the traumatic events.
Anchoring: the client is asked to recite what he/she has learnt from the experience (the positive experience) as the therapists taps the client’s wrist a little more.
Body scan test: to check how the feelings in the body. And to find out what else that is stressful that is felt in the body.
Closing conversation and dialogue: something light hearted, breathing, relaying.
Next session, the previous treatment is rated again to see how the treatment is integrated. If the stress is still there, therapy can be repeated, if it is successful, anchoring work can be done.
Sometimes the client does stabilize after the therapeutic work. It is useful to be patient and listen to the patient’s current experience. The goal of the therapy is not to completely resolve every stress in one sitting, but to bring stability week to week, until the client learns to integrate the treatment.
Often the client feels permanent relief of a certain degree of stress.
I decided to use the tapping technique with a client who mentioned a car accident in which she was a driver that happened 20 years before. She is a successful businesswoman in her 50s, and had never mentioned this incident prior. This incident came to light as a result of a dream recollection.
The client had left a going-away party with some friends, had some drinks. It was also midnight, which was the day of her birthday. As she drove home, she collided with a drunk pedestrian, who got severely injured and died.
During the therapy, the client expressed fear and guilt which she had shut off all the years. She never had a chance to talk about her trauma to anyone and felt lonely.
The tapping allowed the client to see the event as if it were a movie. She could experience the emotions and was able (with hesitation) to vocalize the feelings. Her arms began to sweat. She began to remember more details of the night after the accident when she went home, and the morning after, how she felt like it was a nightmare, but it was for real.
At the end of the session, the client felt her loneliness, but was relieved about being able to share. Her fear level regarding the event went from a high 10 to 0. She still processes sadness and guilt about the event, which was later our work-in-progress.
Schubbe, O. (2004). Traumatherapie mit EMDR
Traumatic events happen in a variety of circumstances. Incidents that happen to us which suddenly shocks us, leaving us overwhelmed, and sometimes frozen, can lead us to experiencing life-long psychological and physiological effects of trauma.
Exposure to traumatic experiences affect us in very individual ways. The consequence of being traumatized, concisely explained, is the effect of our nervous system sensing the danger of the past traumatic experience as if the danger is happening in the present. Harmless situations can trigger feelings of anxiety as a result of trauma.
“The great thing then, in all education, is to make our nervous system our ally as opposed to our enemy.”
William James (1914, Habit)
Since danger and anxiety are buzzwords in trauma, healing trauma in psychotherapy requires big doses of trust. Trust that the suffering from traumatic experiences can be healed. Trust that the psychotherapeutic alliance is a working, trusting one. Trust that, whatever the outcome may be, that the work is worth doing.
This article features part of the very inspirational work of Peter Levine (1997), whose work is a guide for my professional attitude towards trauma.
When working with trauma, it is necessary slow down. Traumatic events and subsequent trigger reactions happen at split second duration, often out of awareness. In the treatment of trauma, the sensory events, feelings and thoughts that arise need to be witnessed with the time slowed down with guidance of the therapist.
Many trauma patients, frustrated at their symptoms, want speedy resolution. Therapists are best advised to reassure their patients, that slowing down is the safer, more effective road to healing.
Traumatic triggers happen out of awareness. The act of slowing down during therapy brings the sensations and thoughts into awareness. It is through awareness that the client gains sovereignty of his/her experiences — and ultimately nervous system.
Levine’s work stipulates 12 basic points of trauma work and experiencing. Some clients benefit when theses points are shared with them. I use this as a map in my work, for effective tracking of the patient’s process and progress.
Psychotherapists who work with trauma know that trauma is locked in the body. Being aware of, and checking into the somatic experience of the client is essential to the work. This is possible when a trusting, therapeutic alliance is already established.
Do seek professional advise if you or someone you know suffer symptoms related to trauma. It is a safer approach to healing than ignoring the symptoms or trying to treat the symptoms unprofessionally.
Levine, P. A. (1997). Waking the tiger: Healing trauma: The innate capacity to transform overwhelming experiences. North Atlantic Books.
This page features a collection of video lectures on the subject of self-harm or Non-Suicidal Self-Injury (NSSI) and its connection to emotional pain. These resources, I hope, will provide some personal and professional answers in dealing with, or appreciating the phenomenon of self-harm.
The aim of this learning is to bring awareness of what is possible and what is needed to assist others with the same issues. Self-harm is a behaviour to be respected because it serves the person. It is also behaviour to be taken seriously, and with compassion.
Willis tells us about the impact of bullying on people who self-harm. He also explains with neuroscience that both physical and emotional pain activates the same area of the brain.
Lewis’ sharing of his experiences of self-harming may resonate with many people. As in the above video, bullying is known to be a trigger for self-harm. Lewis tells us of the value of loving people who are suffering from emotional pain.
Self-harm indicates the need to cope with unbearable emotional pain. The most important aspect of treating clients who have learnt this coping strategy is to authentically respect the person, and what they do and feel. The therapy sessions will then deal with the emotional turmoil that underlies the need to self-harm. The therapist and client work together to understand the origins of difficult feelings. Reminiscing past experiences in a secure therapeutic environment bring up emotions attached to these experiences. As Lewis explains, cutting silences emotions. Therapy brings the voice back to these emotions. This voice is also heard by the therapist who respects the process.
Psychotherapy works through the trauma where the pain resides for the patient. The active ingredient in the therapeutic treatment is the healing of loneliness. In my practical experience, self-harm and suicidality are experienced in deep loneliness. Loneliness is treated through contact in the psychotherapeutic relationship and the therapeutic process.
In a case study in this article, I describe loneliness happening when there is no one to meet us or when we think that no one should meet us at the contact boundary. The healing work of therapy is to meet the client at this contact boundary in the therapeutic field where the pathos experienced.
When a person’s brain is exposed to overwhelming stressful information all at once, the phenomenon is understood as a potential traumatic situation.
Traumatic experiences are combined with extreme fear. What happens is that all the sensations (smells, noise, colors, sights, etc. ) received during the traumatic situation is locked up in long-term memory fragmented.
Non-traumatic or explicit memory, on the other hand, is contextual, conscious and to a certain extent, stable. This type of memory can be re-called or put aside almost at will, can be described, re-worked, and emotions surrounding the memory does not control the person’s here-and-now. The person is able to use this memory to make meaning, learn, make adjustments. This kind of memory is coupled with language and we can talk/write about them.
Traumatic memory, on the other hand is quite different.
Memory from traumatic occurrences can become intrusive. Sensory stimulation from sights and sounds trigger the memories. The individual becomes almost unable to put the memories aside. Emotions from the traumatic situations are felt as if the trauma is still occurring. Sometimes these memories trigger flashbacks. The person is rendered helpless against the flood of the memories.
These memories are also fragmented. The person finds it difficult to put the events into a cohesive whole. Some pieces are forgotten, and cannot be recalled.
Often the memories are decoupled from speech. The person can feel and see the memories in the mind, but finds difficulty in putting the contents of it into verbal language.
Psychical trauma is injury to the psyche, and sense of the self. The consequence of trauma renders a person helpless against being overwhelmed by memories and flashbacks. Therapy with patients of trauma need time, trust and patience. Combined use of verbal and non-verbal communication makes for effective therapy. Empathic communication with the client relieves the individual of the isolation of having to live with such events.
Schubbe, O. (2004). Traumatherapie mit EMDR. Order, 22, 99.
Diane Langberg gives a lecture on Complex Trauma, or childhood trauma, which really is childhood experiences of abuse, neglect, betrayal and isolation. Complex, childhood trauma, is not usually acknowledged by the individuals affected by them. Children exposed to trauma are betrayed by the very people they are dependent on for love. They are, as Langberg describes it, marinated in trauma. As adults, these individuals come to our psychotherapy practice because of other symptoms, like depression, panic disorder or psychosomatic pain.
Langberg provides an explanation of what complex trauma is, how different it is from — and how it is related to– PTSD.
Watch this video of Langberg’s lecture.
I have sketched down notes on this lecture so for quick reviewing of the content, and against the possibility that the video becomes no longer available.
