Lisa Find Love

When it comes to helping children cope with adverse childhood experiences (ACEs) we need to get one thing straight: We cannot help children heal from trauma if we are not equally putting effort towards the mental health of parents and caregivers. In my opinion, the focus is heavily on helping children cope with trauma, which is absolutely necessary, but we are often missing the fact that parents also need treatment and support due to a history of trauma in their life. I know that we are moving in this direction, but with the discovery of trauma being passed down from generation to generation the conversation is more pertinent than ever.

I use the phrase “bottom-up” because the parent is the foundation and roots of the child’s life. A parent’s role is to be a grounding force as children face the challenges and stressors in their young lives. Children need to feel safe and stable in order to thrive. In addition, the parent’s trauma typically happens first and can make a deep and lasting negative impact on the child’s well-being. 

First, let’s uncover what transgenerational trauma is. Transgenerational trauma is a form of trauma that is passed down from generation to generation through behaviors, beliefs, and potentially biology. Yes, biology. There is circumstantial evidence that suggests trauma can be passed to our offspring genetically. If this is the case, how can we continue to ignore the impact of trauma on everyone’s future, including those who did not directly experience it? Types of trauma that are especially prone to transmission to future generations are:

• Extreme poverty
• Racism 
• Abuse and neglect
• Witnessing violence
• Sudden death of a loved one
• Military experiences 
• Terrorism
• Ambiguous loss

The good news is that, although trauma can be passed down, emotional resiliency can also be passed down to our offspring. That’s why a bottom-up approach is crucial to stop the cycle of trauma taking place in our world today. 

Overcoming trauma does not happen in a vacuum. Even if progress is made in the counselor’s office, a child’s progress will unravel, when they return to the dysfunction taking place in the home. We need to look at trauma not as one event that takes place, but as a constellation of events that invade one’s mental health and their ability to cope with everyday stressors, like parenting. When a parent/caregiver is living with unprocessed trauma, raising a child can trigger memories of abuse and neglect that interfere with their ability to regulate their emotions. These triggers make it difficult to make healthy parenting decisions in the heat of the moment. 

As professionals we will ask ourselves how to reach the parent with trauma, and it starts with building trust. At the root of trauma is a foundational breach of safety and trust. By shifting our perspective to look at the caregiver as someone who is not broken, but coping the best they can with unprocessed trauma, we will be able to make connections that might not be possible otherwise. We will not be able to reach all caregivers, but if we are able to meet a fraction of them where they are and truly care for them, we will be making a massive residual improvement on the lives of children and the world at large.

As a therapist who worked closely with the child welfare system, I witnessed countless children struggling with trauma and loss who were unable to access treatment. As a current volunteer advocating for children in the foster care system, I have a young child on my caseload who is not receiving treatment for the trauma and neglect she experienced because “she seems ok.” This is not due to a lack of concern, but because of inadequate mental health resources for children in the child welfare system.

So what does transgenerational trauma look like? This is an example from my perspective as a family therapist: A person with untreated mental health challenges and or a history of trauma chooses to self-medicate with drugs, alcohol, or sex out of sheer desperation and a lack of coping skills. This person has children. These children are exposed to trauma, abuse, and neglect by their parents typically in relation to addiction. Out of a need for safety, the child is removed and placed in foster or kinship care. The child doesn’t receive the necessary mental health treatment due to a lack of resources. This child seems “ok” while young, but as they reach adolescence, they begin to exhibit symptoms of complex PTSD, anxiety, and depression.

Meanwhile, untreated mom and dad continue to have children who end up in the care of others. The child/teen of untreated parents begins to self-medicate with drugs and alcohol to cope with the trauma they experienced and the cycle repeats. This is how trauma is passed down from generation to generation. There is also evidence arising in research that trauma can be passed down to children through their DNA, but more studies are needed in this area to confirm.

So how do we interrupt the cycle? It’s not a simple answer, but it starts with building awareness. It begins with conversations and relationships. It begins with ending the stigma of mental health care. It begins with making treatment mandatory for children in the foster care system. It’s using a wide-angle lens on the child’s trauma as an extension of their parent’s trauma.

We are only now becoming aware of how adverse childhood experiences (ACE’s) impact the health and wellness of our society as a whole, but this is no excuse. Now that we know better, we need to do better.

The Bottom-up Approach for Stopping Transgenerational Trauma

• Trauma therapy for the child needs to happen in tandem with the adult caregiver. Isolated trauma therapy for a child will not succeed when the caregiver is not part of the therapy process. This includes biological parents, foster parents, and relatives caring for children.
• Any child in foster care or kinship care has experienced trauma, often complex trauma, and is at risk for serious mental health issues. They need and deserve treatment regardless of their “ok” status at 2, 8, and 12 years old.
• Screen for trauma first! In many cases with children in care, it’s not oppositional defiant disorder (ODD), ADHD, or ADD; it’s trauma. Look underneath the behavior, and you will find the cause is often a history of untreated trauma. The child may appear to have ADD/ODD because their nervous system is on high alert for danger, making it difficult for them to sit still, regulate emotions, and concentrate. We need to stop automatically pathologizing the behavior of a child and medicating them without screening for trauma first.
• If a child’s caregiver or parents have a history of unresolved trauma, they need access to personal counseling or parenting coaching so they are not triggered by their past while parenting. A parent who is emotionally unregulated will not be an effective parent for a child who is trying to learn emotional regulation skills. Co-regulation is a process that takes place at birth between child and caregiver, and it is crucial for healthy emotional development. If a parent is unable to regulate their nervous system, the child will not learn how to regulate their nervous system.
• Trauma doesn’t destroy the person, it destroys their trust. Heal trust; heal trauma.
• Empower the parent by caring about their mental health and providing education on trauma-responsive parenting skills.

We can prevent the transmission of transgenerational trauma by intervening early and often with parents and children at risk. I know we can do better for the well-being of our communities. I know we can do better for the safety of children. I know we can do better to stop the unnecessary cycle of trauma. I have hope, and hope is where change begins. I ask you to join me.  

Ela was happily married — or so people thought — until the day her husband came home with a DVD he had bought. Not a common practice for him. The name of the movie was Sleeping with the Enemy with Julia Roberts. Ela loved movies and made some popcorn to watch it with her husband. “Who recommended it?” she asked.

“Myself,” he responded. “I think it’s time for you to wake up.”

That day marked the beginning of Ela’s understanding of her dissociation, her depression, her submissiveness, her lack of enjoyment, and many other symptoms that she had developed through several years of emotional abuse and neglect, manipulation, gaslighting, and objectification at the hands of her husband.

Complex Trauma Diagnosis

Complex Trauma was first described in 1992 by Judith Herman in her book Trauma & Recovery. Immediately after that, Van Der Kolk (2000) and others began promoting the concept of “Complex PTSD” (C-PTSD), also referred to as “Disorder of Extreme Stress Not Otherwise Specified” (DESNOS).

According to Herman, complex trauma occurs after repetitive, prolonged trauma involving sustained abuse or abandonment by a caregiver or other interpersonal relationships with an uneven power dynamic; it distorts a person’s core identity, especially when prolonged trauma occurs during childhood.

DESNOS (1998) was formulated as a diagnosis with all the criteria and proposed in 2001 to be added to the DSM-5 as an option for complex trauma focused on children. It stated that childhood abuse and other developmentally adverse interpersonal trauma produce impairments in affective, cognitive, biological, and relational self-regulation. The proposal was rejected. 

Christine A. Courtois and Julian Ford expanded on the concepts of PTSD and DESNOS arguing that complex trauma generally refers to traumatic stressors that are interpersonal — they are premeditated, planned, and caused by other humans, such as violating and/or exploitation of another person; repetitive, prolonged, or cumulative, most often interpersonal, involving direct harm, exploitation, and maltreatment of the sort; neglect/abandonment/antipathy by primary caregivers or other ostensibly responsible adults, and often occurring at developmentally vulnerable times in the victim’s life, especially in early childhood or adolescence. Complex trauma can also occur later in life and in conditions of vulnerability associated with disability, disempowerment, dependency, age, infirmity, captivity, confinement, bondage, and so on.

After all the argumentation, Complex Posttraumatic Stress Disorder (C-PTSD) has been recently proposed as a distinct clinical entity in the WHO (World Health Organization) International Classification of Diseases, 11th version (ICD-11), due to be published soon, two decades after it was first proposed. It has been said that it will be an enhanced version of the current definition of PTSD, plus three additional clusters of symptoms: emotional dysregulation, negative self-cognition, and interpersonal hardship.

C-PTSD then is defined by its threatening and entrapping context, generally interpersonal in nature, and will keep the requisite of “enduring personality change after a catastrophic experience.”

The criteria seem to be asking for significant impairment in all areas of functioning, and:

• Exposure to an event(s) of an extremely threatening or horrific nature, most commonly prolonged or repetitive, from which escape is difficult or impossible;
• All diagnostic requirements for PTSD, and additionally:
  • severe and pervasive affect dysregulation;
  • persistent negative beliefs about oneself;
  • deep-rooted feelings of shame, guilt or failure;
  • persistent difficulties in sustaining relationships and in feeling close to others.

In summary, C-PTSD will be a diagnosis included in the CDI-11 — as an extension of PTSD — that will consider prolonged exposure to emotionally challenging events that are sustained or repetitive, from which escape is difficult or impossible.

Complex Traumatization

Like trauma in general, what actually causes complex trauma is not only the type of terrifying situation(s) we go through and have to endure, but the fact that our mind gets engulfed in the terror/fear/drama of the event, and succumbs — consciously or unconsciously — to the belief that we are “doomed.”

I know that this is not the traditional way of thinking about trauma; it’s easier to “blame” the event, and think it is normally caused by something or someone else, and wishing someone could be held accountable for our suffering. It should be, but it normally doesn’t happen. The person that stabs you with a dagger is never the one that does the stitches to close the wound. If the person “holding the dagger” is not accountable, “the dagger” is even less. There is definitely an external cause for trauma, but to protect ourselves from traumatization, it becomes more important to focus on the wound and not on the weapon. If we understand how we internally and unconsciously “participate” in the development of complex trauma, we could stop it.  

Besides the external reason, complex trauma is caused by the way the brain understands the instructions from our thoughts, which normally come from our emotions. 

For example, if we feel fear (the emotion), then we get scared (the thought that we are in danger), and then our brain will activate the defense that is designed from birth to protect us from danger. The brain doesn’t care if the danger is about a mouse, a bomb, or an abusive partner. The brain just reacts to our perception of being at risk and triggers the defense mechanisms.

Why does trauma happen? Trauma — defined as the semi-permanent alteration on the functioning of the nervous system after traumatization — happens because the brain doesn’t receive the instruction to go back to normal. In the case of complex trauma, it stays activated in a loop of reactivity thinking that it still needs to protect the system from perishing. The traumatization is the state of fear of being at risk, where the system is trying to avoid the source of danger without really finding a solution. Trauma is the result, the injury, the wound left as a maladaptation after that loop of fear and hopelessness.

Complex trauma is the result of sustained traumatization due to the perception that the risk is constant, and there is no way to escape from that state of insecurity; the brain “decides” to submit and surrender as the solution to surviving, and stays in self-defeating survival mode as the new way to operate.

Complex Traumatization Loop

Hence, complex trauma doesn’t happen overnight. For someone to develop complex trauma, the brain goes through a loop of traumatization following a sequence that goes like this (you can also follow the diagram):

• there is danger,
• we experience fear,
• we get scared (thoughts and concepts),
• our brain interprets the affect of fear and the thoughts of “I’m scared” as instructions to activate the defense that is designed from birth to protect us from danger located in our emotional brain;
• fight-flight tries to protect us by priming us to punch, kick, run, etc. Anger adds to the fear;
• if we CAN defeat the adversary (source of danger) using either our strength or our anger/rage, or if we CAN escape from it by “leaving,” our system will go back to normal. It may take some time (from minutes to days) but it “reboots” the system and we recover our baseline;
• if we CANNOT defend ourselves by fighting — because we don’t have the capacity to control the abuser — or if we subjectively feel that there is no way out — maybe because there is some type of dependence or domination — or if we objectively can’t win, then fear increases;
• anger may be suppressed or replaced by frustration, exasperation, discontent, disappointment and/or more fear, and a sense of helplessness or overwhelmed appears;
• those emotions trigger more intense defenses, like submitting, or getting immobilized — not in an attentive way, but in a collapsing way — trying to find a solution to stop the feeling of being in danger; submitting or becoming subjugated could be the strategy looking to regain safety — “if I’m submissive, he/she will stop hurting me (or love me again)” type of thinking;
• now the brain has defenses activated that are arousing — as in fighting-fleeing — and defenses that are setting the system into an inert mode — as in collapse or faint. The emotional brain remains scared combined with anger, hatred, and disdain, but still feeling the need for safety; sadness, defeat, disappointment, hurt, resentment, start building up;
• if the person is experiencing total terror or total exhaustion, the feeling of hopelessness may arise;
• the brain will interpret hopelessness as the instruction to keep activating the defenses and the system will move into working focused on surviving, whatever the cost. The cost is dissociation, numbing, shutting down, depression, depersonalization, memory loss, anxiety, etc.
• If the person, instead, decides to submit, accepting the situation, and controlling the terror and hopelessness (using resilience and cognition), the brain will interpret the reduction of the fear as the instruction of not needing to continue in defense mode and will deactivate the defenses;
• if the terror or fear disappears because the person’s assessment of the risk is such that reaches some sense of safety or hope of being ok — like making plans to leave, believing that the situation is improving, or even thinking in revenge — the brain will stop the defenses and will start rebooting the system to go back to normal (it may take months to years, but it will work hard in recovering balance soon and to optimize functioning).
• If, instead, or at any point, the person CANNOT get back his/her cognitive functions to find a way to feel safe, the emotional brain will stay living in fear and hopelessness, and will have the defenses active permanently; it will become the new way to function for that brain and that repetition of the loop will cause what we call complex trauma.
• The defenses will keep shooting stress hormones, destabilizing the production of, and the vital functions like digestion, temperature, heart rate variability, sweat, etc., losing internal equilibrium (loss of homeostasis).
• This new constant way of living in hyper-alert with no hope or trust, just looking for danger or defeat, will be a loop of endless re-traumatization that will end up damaging perception, cognition, emotions, introspection, action, behaviors, and brain/organ operation and connection that will generate all sorts of symptoms, not only related to mental health but also physical health.

This sequence, departing from thoughts and moving into reactions, defenses, overwhelming emotions, and disturbed mental states, is what causes and becomes complex trauma. 

Ela would visit several doctors for all sorts of aches and pains before she realized that her problems were rooted in the abusive relationship she was in. She kept herself mentally “stable” for years carrying an eternal sense of dread and sadness that just a few noticed, but her body was not able to stand all the physiological consequences of the complex trauma. It was not until she fell into a deep clinical depression that the C-PTSD was identified. Ending the abuse was imminent; otherwise, her complex trauma would have continued unfolding. By making the decision, the submission subsided and she started healing.

The patient/doctor relationship has to be one of  honesty and insight. I have to be honest with my doctors and tell them what is going on. If I am honest, I have nothing to hide. I know my doctors are here to help me and not to hurt me, so being honest with them about what is going on in my life, as well as what symptoms I am experiencing, will help both of us to do a better job. 

I have confidence in my doctors’ ability to both diagnose and treat my severe mental illness. They have vast experience and knowledge in the treatment of schizophrenia. When I was first diagnosed I began to do online research myself to learn about my illness. One of the things I learned was that many other people have the same diagnosis as me, and I could learn from their experiences too.

My doctors have worked with me during a trial and error period of learning which medications could most effectively treat my schizoaffective disorder. I have been on several medications. I know my doctors do not want me on a dosage that is too high. In my attempt to help them understand my symptoms and prescribe the correct medication, I regularly write down my symptoms in a journal which they use to treat my illness in the best way. There have been instances when I did, in fact, feel I needed a change in my medication. My doctor listened, which a good doctor will do, and my dosage was changed.

A few years ago one of my doctors gained access for me into a national study of an older antipsychotic medication. It took awhile to get use to this new medication, but once it started working, it has been a game changer for me. This medication requires that I get monthly lab work done, but this can be accomplished when I am seeing my doctors for regular monthly visits.

On my current medication most of my days are symptom free. My psychiatrist, however, brought it to my attention that some of my medications could have a side effect that may cause me to gain weight. In an effort to combat weight gain, I exercise regularly and try to watch my food intake. I try not to snack at night, and I eat lots of fruits and vegetables.

Early in my treatment for schizoaffective disorder, one of my doctors prescribed a once monthly injectable. However, at that point I was in denial about my alcohol use which was a very unhealthy routine, making my injectable ineffective. After I gave up alcohol in all forms, I asked to be put back on the once monthly injectable because of the convenience of not having to take a pill every day. Starting back on the injectable was one of the best things I could have done for myself. The once a month injectable has not only made most of my symptoms disappear, but it has made me more sociable and less of a recluse. 

I considered it a compliment when one day my psychiatrist told me that I understand my schizophrenia better then most of her other patients. Her comment was an important stage in my recovery. It made me realize I am managing my symptoms well, and that has contributed to my overall well being.

Sessions with my psychologist have helped me to learn more about my diagnosis. For example, once when I was describing a voice I frequently hear, my psychologist told me this type of annoying voice was called a commentary voice. Based on what I had experienced, this made perfect sense to me. It blew my mind there was a word for what I was hearing, and that others had the same symptom.

During one therapy session, that same psychologist shared the diagnostics manual for mental illness with me. I saw the many symptoms of schizoaffective disorder. I learned that bipolar and schizophrenia can be very similar. Seeing my symptoms and diagnosis in print in this medical manual made me realize I am not alone, and it explained what I was hearing and seeing.  There is a definitive description for what I am experiencing.

In the years since my initial diagnosis I have had one psychologist, but a multitude of psychiatrists. Most of them moved on to other positions at different hospitals. I begin each new relationship with an open mind understanding that I may have to repeat my medical history. I understand that because I am getting treatment at a veterans’ hospital these doctors see many patients every day. If I can help them to help me, then our relationship can move forward with trust, honesty, and expediency. I have been blessed that I have had good doctors in my mental health recovery. We are part of a team — each with an important role to play. If I will effectively do my part, together we can make the best decisions for my health.

Therapy and the Brain

It seems ironic that after Freud, as a neurologist, abandoned his studies on brain functioning to replace them with the studies of the unconscious — and that he actually abandoned his studies on traumatization — the trauma therapy world is arriving to a point comparable to the point where he started: the understanding of the brain as the basis of understanding the mind.

Trauma therapy is leveraging neuroscience because having an understanding of how traumatization affects the brain helps to not only dismantle common misconceptions and to stop victim-blaming statements, but it also explains many of the common behaviors and experiences of survivors experiencing either excessively stressful events, or prolonged intensely dysregulating circumstances.

After a focus on treating the brain with drugs (medication), and the mind with words (talk therapy), today neuroscientists have broadened the scope by studying the molecular, cellular, developmental, structural, functional, evolutionary, computational, psychosocial and medical aspects of the nervous system. 

These advances are finally finding solutions in the same ways that the father of psychology was trying to find them almost a hundred years ago. Wilhelm Wundt (1832-1920), a physician, physiologist, and philosopher, started his interest in human behavior as an assistant of Hermann Helmholtz, one of the principal founders of experimental physiology, when psychology was part of philosophy and biology. Helmholtz was interested in neurophysiology and was conducting studies on the nervous system and the speed of neural transmission. That influenced Wundt to use equipment of the physiology laboratory to conduct his studies, which helped him in founding the first formal laboratory for psychological research in 1879. 

Many other scientists of the 19th century were studying brain functioning in ways that helped psychology methodology and treatment to develop. Unfortunately, electroshocks and lobotomies were thought to offer great solutions and discredited the studies later on. 

With the creation of psychoanalysis — and Freud’s strong personality — most of the attention diverted from the laboratory to the couch, and from the brain into the exploration of the unconscious, and, therefore, the world of thoughts. 

In the same decade that the Berlin Psychoanalytic Institute was founded (1920), Hans Berger — a German neurologist and psychiatrist — published human electroencephalogram (EEG) data for the first time in history. He described a pattern of oscillating electrical activity recorded from the human scalp and demonstrated that alterations in consciousness correlate with EEG shifts. 

Berger felt that the EEG could be useful diagnostically and therapeutically by measuring the impact of interventions, thinking that the EEG was analogous to the EKG (electrocardiogram). That type of investigation was cut off from the psychiatric world for reasons that escape my understanding. 

Wouldn’t it be just logical to think that if every regular doctor uses technology for diagnosis like the EKG, every mental health professional would use the same type of support to have a better understanding of how the brain is working?

It was not until the beginning of the 1970s that the discoveries of the relationship between brain and mind started to bear fruit; neuroscience and the advances in neuroimaging have contributed in a way that allow mental health professionals to realize that understanding the brain adds perspective to the therapeutic modalities that already exist, and complement them. 

Diagnosing Trauma

Reviewing the literature on psychotherapy, the importance of the Diagnostic and Statistical Manual of Mental Disorders (DSM) since its creation in 1952 is notable. The current DSM-5 came out after fourteen years of discussions — and battling criticism — based on all previous experience to regulate the assessment of mental difficulties. 

Still, some professionals state that this latest version is likely the one that clinicians have given the least attention to, probably because it is the least useful for the treatment of mental problems (Pickersgill, 2013). We have seen many symptoms and disorders come and go into the different versions of the manual, and we are still lost in terms of identifying what’s normal, what’s treatable, what’s deviant, and what should be covered by insurance as a curable mental condition. Even insurance companies stopped using it to classify billable disorders, using the WHO manual instead.

The problem with the DSM is not whether we find a consensus in how to call or classify human behavior; the problem is that the DSM is what sets the tone for developing treatments. We can take the words of Walker & Kulkarni from Monash University, who wrote the following about Borderline Personality Disorder: “BPD is better thought of as a trauma-spectrum disorder — similar to chronic or complex PTSD.” That’s also the case with several other disorders that are treated as flaws in the personality or behavior instead of addressing the origin of the issue as traumatization and problems in the functioning of the brain and nervous system. 

Nassir Ghaemi, author, and Professor of Psychiatry at Tufts and Harvard University School of Medicine calls the DSM a failure and states that the “DSM-5 is based on unscientific definitions which the profession’s leadership refuses to change based on scientific research.” There is a clear connection between that statement and the fact that the DSM refuses to recognize traumatization and its consequences on the nervous system, as well as ignoring trauma’s phenomenological relevance in the mental health arena. 

Mostly because of this, the majority of therapies (and therapists) have not yet moved from treating behavior and thoughts to treat what propels those actions and ways of thinking. For treatment to be successful, the alterations on brain functions, and their relationship with all aspects of personality, emotional experiences, and thought processes, need to be included in treatment, together with the identification of the dysregulation of the autonomic nervous system (ANS).  

Trauma Spectrum

Part of the challenges of trauma therapy is to recognize the type of alterations that the person suffers from. We don’t count with enough diagnoses to use them as road maps. Trauma therapists need to go deep into investigating circumstances in order to find out what type of traumatization the client had to endure. 

The same way there are different events that cause trauma, there are different types of manifestations of traumatization, depending on what branch of the ANS got more damaged and suffered the more severe alterations.

• If the caregiver is emotionally absent even if caring and dedicated, the baby can suffer from lack of attunement and develop attachment trauma. This type of traumatization can go undetected for years and has terrible consequences in the health and mental health of the person that never learned to regulate the balance between the branches of the ANS.
• When there are just few concepts, but mainly disturbing body sensations and emotional needs, not receiving response to a discomfort — like hunger — or not getting the child’s despair consoled, could be paramount and seed the root of developmental trauma. The nervous system stays in constant confusion, feeling the need to attach and the fear of rejection, over activating the parasympathetic nervous system and staying a long time in immobilization mode. That causes brain developmental issues, dissociation, depressive mood, learning disabilities, etc.
• If the stressful events are recurrent and for a prolonged period in life, the traumatization can be as significant as if the events were terrible and can be the origin of developing complex trauma. This type of traumatization can have either branch of the ANS overriding the other and presenting extremes on hyper or hypo arousal.
• If someone fears the impact of his/her participation in society because of her/his skin color, racial trauma can be in the making. The ANS manifests similar activation as complex trauma, but the expression seems to be more acute.
• When a parent’s high levels of anxiety significantly interfere with the child’s developmental progress, and the child’s self-image and object relations are also obviously affected by the image of the parents, the child’s shame or confusion about their parents or previous generations can evolve as historical or intergenerational trauma.
• When a person suffers from different types of traumatization early in life, the combination of the dysregulation and its behavioral manifestations combined with temperament can end up manifesting as personality disorders.

Neurobiology-Informed Trauma Treatment

Trauma treatment is informed by the sequelae of alteration on the ANS after traumatization, and proceeds accordingly. The symptoms are treated as components of trauma treatment as opposed as separated disorders. The modality chosen depends on the area that needs improvement (cognition, affect, memory, identity, agency, mood, etc.) and on the phase the treatment is at.

Ruth Lanius is one of the clinicians that is using all sorts of modalities with her clients, including EEG and neurofeedback (NFB) as the basis to understand the brain and regulate it. As the director of the PTSD Research Unit at the University of Western Ontario she conducts research focused on studying the neurobiology of PTSD and treatment outcome research examining various pharmacological and psychotherapeutic methods. She is presenting great results reprogramming brain functioning with NFB among others.

Trauma therapy works against the stigma of mental health by repairing the malfunctioning of some areas of the system instead of working on finding character flaws and fixing the “defective” person. Using a compassionate and scientific lens, trauma therapy helps clients develop self-compassion and acceptance. 

Freud called psychoanalysis the third impossible profession (the other two being education and government). It may be as valid to say that psychotherapy is another impossible profession. Many therapists desire to master several of the countless therapeutic modalities available today in their endless pursuit to feel more adept at offering hope, especially to the large number of individuals looking to alleviate the despair rooted in the experience of traumatization. Trauma therapy requires mastering several modalities and unlearning most of what therapy was before. Not “impossible” but definitely a fascinating and arduous journey for the therapist — and for clients. 

I wonder how therapists felt when psychoanalysis (and behaviorism) dominated the world of psychotherapy all through the first half of the twentieth century.

I picture the beginning of this contest developing as the paradigm shifted to a person-centered school, and the appearance of humanistic psychological therapies in the 1950s and 60s. That, in tandem with the emergence of psychotropics and closing of mental institutions, must have been the reason why a revolution in the treatment of mental illness kicked off.

We are now in a very important moment in the history of psychotherapy, confronting another paradigm shift: traumatization. Foderaro (1995) stated it beautifully: “the fundamental shift in providing support using a trauma-informed approach is to move from thinking ‘What is wrong with you?’ to considering ‘What happened to you?’”

Traumatic Events

It was not until recently that trauma came to occupy a place among mental disorders, receive the attention that it deserves, and obtain the recognition for the magnitude that it has. Yet, there are no official diagnoses for the several different types of traumatization, and the DSM-5 still requires the person have been exposed to death, threatened death, actual or threatened serious injury, or actual or threatened sexual violence to meet the criteria.

To understand the individual’s challenges and for therapy to serve them well, it is important to have in mind how traumatic an event is rests on each individual’s resilience. The response of an individual to “traumatic events” depends not only on stressor characteristics, but also on factors specific to the individual — out of their control, awareness and power.

Any event could be traumatic if the reaction to it exceeds the capacity of the person to stay regulated and to bounce back to normal functioning. Events that cause trauma can be of all sorts; to name a few, they can include:

• abuse of power,
• betrayal of trust,
• entrapment,
• helplessness,
• pain,
• confusion,
• loss,
• sadism,
• cruelty,
• criticism/bullying,
• rejection,
• absence of control,
• lack of attunement to the parent,
• and factors like oppression, discrimination, poverty, racism, or even malnutrition.

I hope this concept is clear: traumatization is about how a person experiences an event/circumstances/emotions and that each one’s experience is subjective. Traumatization depends on the person, not on the event itself.

Trauma Psychotherapy

This is a very interesting moment to be a psychotherapist. Many modalities are introducing neuroscientific concepts to elucidate their efficacy, and several of them are using neuroscientific discoveries as part of their core. Psychology, physiology, anatomy, technology, and even Eastern and Western philosophies are all converging, and we are getting much better equipped to help people live more fully.

Trauma therapy is newer than the recognition of trauma as a disorder. Post-traumatic stress disorder (PTSD) is only 40 years old. Interdisciplinary debates involving philosophy, psychology and psychopathology (Aragona et.al 2013) are taking place constantly, contributing to our understanding on how the brain is related to our emotions; the report of the central role of mirror neurons on empathy just came out 7 years ago.

Therefore, we can say that trauma therapy is still in the making.

So far, what we can say about trauma therapy is that it differs a lot from “traditional” therapy in the sense that it is less about thinking and talking, and more about doing and experiencing.

Trauma therapy is more structured and directive, it’s highly relational, and it’s truly compassionate. It doesn’t pathologize the client, it gives the client the authority of owning his/her interpretations, and it sees the symptoms as a consequence of what happened to the client instead of identifying the client’s behavior as a sign of defectiveness. 

Trauma therapy is not talk therapy; working with a trauma therapist is not talking about terrible memories as soon as the relationship starts. Trauma therapy is highly informed by neurobiology. For this reason, it has the understanding that exposing clients to their traumatic memories too soon is counterproductive and can even be re-traumatizing.

If you work with a trauma therapist, you don’t need to go in prepared to constantly cry. Instead, you could prepare by wearing comfortable clothes because you may move around — many interventions include body movement, posture, sensations and physical interactions.

Be prepared also to learn about yourself inside out: from how your nervous system works to how society influenced your symptoms. Instead of spending your session talking about others, you’ll go in and develop a conversation with and about you. Instead of finding who to blame, you will be working on how to recover agency, confidence, self-esteem, sense of self, and peace of mind. 

Trauma Therapy Phases

Most of the literature for trauma treatment suggests a 3 phase treatment based on how Pierre Janet envisioned — more than a hundred years ago — a phase-oriented way to treat trauma. Despite the steps being defined so long ago, trauma treatment was not implemented until the late ’90s by Judith Herman’s book “Trauma and Recovery.” That design consists of:

Phase I: Stabilization

Phase II: Processing

Phase III: Reprogramming 

The model has been modified a little to include more development of resources and emotional capital, and it’s seen now as more circular than linear, but the philosophy is basically the same: 

Stabilization

Probably the most important phase of the trauma treatment; even more important than processing the traumatic memories. If this phase is done in an effective way, the processing of the emotionally loaded material from the past could go smoothly and fast. It has several steps:

• Establishing safety
• Psychoeducation
• Self-regulation

Establishing safety (living situation, health, habits, income, wellbeing, etc.) is one of the steps that many other therapies don’t include. It comes from a biopsychosocial model than from a psychological one. Traumatization is rooted in lack of safety; therefore, it’s just logical to see how individuals can’t heal from the fear of feeling at risk if they are at risk. Trauma therapists work on safety from checking on the client’s diet and addictions, to abusive relations, to risky behavior, to ownership of weapons.

Psychoeducation is also pretty novel in the therapy world. A trauma therapist could have a whiteboard at the office, and will give handouts with charts and explanations learning to instruct on how to develop:

• regulation skills
• tolerance to affect
• awareness of emotions-reactions-triggers
• resilience
• reaching a point where emotions and memories are manageable without overwhelming the system

Self-regulation is about developing regulation skills to deal with the dysregulation of the autonomic nervous system caused by traumatization. We know that the nervous system emerges from the assemblage of neurons and nerve cells that are connected to each other and that the core component of the brain is the neuron. To understand trauma and how to treat affect regulation it becomes helpful — if not necessary — to have some knowledge of the sophisticated activity of brain, the neurons and their circuits. Self-regulation is the point where the individual acquires enough capacity to control emotional reactions, and the reprogramming of the brain starts. The alterations left by the traumatization begins to return to the previous way of operating and equilibrium gets recovered.

If the trauma is developmental — or complex (C-PTSD) — there is a need to strengthen the prefrontal cortex, to develop trust, to discover how to attach securely, and to learn how to reparent the infant’s wounded self-parts.

Processing

This phase includes integrating the story of the traumatic event into a cohesive narrative by achieving memory reconsolidation, which means replacing the negative emotional charge of the original memory with a more appropriate emotional significance, according to the actual circumstances. Processing helps recalling — or not — the events, finally making sense of the past, and not carrying the dread that has been there all the time since the traumatic event(s).

Reprogramming

This stage is where the individual reconnects with others, rewrites the story, develops social skills, and mourns all the losses from the years spent in survival mode.

Trauma Modalities

Since trauma is a disorder based on the dysregulation of the nervous system that affects the personality, the memory, the mood, the behavior, etc., it needs more than one modality to go through the healing process. Modalities are a series of techniques adhering to a specific philosophy about how to target specific problems, to solve them. Most trauma therapists train in at least 2 and attend countless workshops to become proficient in the 3 phases. What the sessions look like depends on the modality that the therapist is using. They can be top-down sometimes, or bottom-up others. They can be body-based, or more cognitive, or more energy-oriented, or they can even use computers and cables connected to your skull.

The most common modalities for each phase are:

Stabilization:

• Mindfulness (ACT, CFT, etc.)
• Yoga, Tai Chi, Theater, EFT, etc.
• Hypnosis, EFT, Hakomi, Gestalt, Schema therapy, etc.
• Parts language (from IFS, sandbox, etc.)
• Biofeedback (breathing, HRV)
• Neuromodulation (Entrainment, brain stimulation)
• Neurofeedback

Processing:

• EMDR
• Somatic Experiencing/Sensorimotor Psychotherapy
• AEDP
• Internal Family Systems

Reprogramming

• Narrative therapy
• Positive psychology
• Grief and loss counseling
• Social skills training
• Hypnosis
• etc.

Trauma therapy is empowering.

Trauma therapy is not about coping with symptoms, it is about healing. It’s about helping individuals to recover their whole self, and to get their lives back.

Forget everything you thought you knew about anxiety and perfectionism. Here’s an inside look at what actually works.

We all feel the need to be accepted, to fit in, feel loved, and that we matter to someone or something. 

As someone who struggles with anxiety myself, I understand how hard it is to combat the anxiety feedback loop. As a psychologist who has worked with this material for nearly a decade, I supposedly know all the tricks in the book. I have a tool kit 10 pages deep ready to go whenever I experience a bout of anxiety. Even still, I struggle to practice what I preach. 

Moving beyond this feedback loop induced by perfectionism, fueled by people pleasing tendencies, and manifested with anxiety is challenging. Over time, I eventually learned to manage this perfectionism induced anxiety by cognitively restricting my thoughts, practicing exposure therapy and learning how to recognize my panic triggers. It is somewhat counterintuitive, but I have found that rather than pushing away intrusive thoughts, our anxiety melts away when we hold space for these overwhelming thoughts. It is the ultimate paradox of anxiety, and the theory that is at the roots of exposure therapy (often used for social anxiety, phobias and PTSD).

In my practice, I hear clients doting on their status as a “perfectionist.” Pulling all-nighters as if it were a badge of honor. Settling for nothing less than outstanding. Entering into a competition solely to win. While on the outside, shooting for the stars may seem like a good idea. After all, we live in a meritocracy that values outputs overall. But there is a darker side to perfectionism that I would like to explore. 

So, what is perfectionism and why is it dangerous? 

Perfectionism is the act of aiming to achieve totally irrational standards; doing everything better than everyone else. A perfectionist is driven solely by the expectations of others and derives their entire self-worth from external standards. They have fallen prey to overly harsh self-criticism and struggle to free themselves from the people pleasing paradigm. 

As a psychologist, coach and anxiety healer I work with young, brilliant, high-achieving women who nearly all describe themselves as “perfectionists.” They inevitably share one or some of the following personality traits: 

• All or nothing thinking. The perfectionist is the ultimate black or white thinker; a pattern that is very common in people with anxiety and depression. The all or nothing thinker will settle for nothing in-between and will often dwell on self-defeating thoughts. This is a dangerous cognitive distortion that puts the person into one of two camps: a success or a failure.
• Fear of failure. Also called atychiphobia, there is complete paralysis experienced when we let fear stop us from moving forward. Oftentimes I see bright, capable young women shy away from attempting a task because it comes at the cost of “a chance of failure.” They can justify inaction, but not a failure. Fear of failure is deeply rooted in one’s sense of worth and can stem from having critical parents.
• Behavior rigidity. This is defined as complete and utter inflexibility when it comes to food, choices, outcomes, school, career, and friendships. In a person with behavior rigidity, every relationship, every interaction, everything we eat propels us closer towards this ideal standard. Researchers have discovered one of the strongest predictors of developing an eating disorder is behavior rigidity (Arlt et. al., 2016). One reason for this is that disordered eating and perfectionism share some common features: fear of social evaluation and inability to adapt to new situations.
• Inability to trust others to handle a task. No one can do it as well as the perfectionist. This is why we so often see the perfectionist agreeing to take on 100% of the project or rejecting inputs from others, even if it costs them their sanity. The fear of relinquishing even the slightest bit of control is too powerful, so the perfectionist pushes other attempts at help away.
• Waiting until the last minute to get things done. Because, if you fail, there’s an easy excuse. “I did not get started until last night at mid-night, so I did not expect my work to be recognized.” Placing the blame on something outside (but ultimately within your wheelhouse of control) is the absolute perfectionist tendency. Failure can then be attributed to lack of effort rather than lack of skill.

It is no secret that increased levels of “perfectionism” lead to higher levels of depression, lower self- esteem, and disordered eating. Several studies have examined the relationship between perfectionism and anxiety (Alden, Ryder, & Mellings, 2002), revealing strong links between the two traits. So, is there hope? Are perfectionists doomed to repeat this cycle of anxiety, fueled by external validation and high levels of self-criticism? Not at all. 

The good news is when we learn how to foster a sense of intrinsic motivation, we can shift our focus TOWARDS pleasing ourselves and AWAY from pleasing others. So, how do we develop intrinsic motivation? And why is it so challenging? 

1. Spend some time alone.

Take a day, heck — maybe even a week, off from consuming any sort of media. When you experience a down moment, turn inward rather than outward. Sit with your thoughts. My guess is you have probably never done this. And if you have, these moments are few and far between.

The connection between what you desire and what the world desires from you will become illuminated when you take the time to quiet your mind. Listen to your thoughts. What comes up when you spend time alone? What do you like? What fills your soul? Let this energy seep in.

Spend a few hours each day reflecting on this newfound spark and let this energy fuel your identity and self-worth. You will be delighted to see how drowning out the external noise can do wonders for your ability to create your own light. 

2. Recognize no one cares.

No one is paying attention to the details of your life like you are. A harsh wake-up call, but incredibly liberating once you actually realize. I love it when my young clients actually embrace the profundity of this. Once you begin to recognize this truth you are liberated from the grip and expectations of others. Embracing this truth provides you with the space to dive into your talents, desires, and creativity — free from the expectations of others.

When I am working with women to overcome their anxiety, we focus on creating space between a thought and a reaction. (This is the premise of Cognitive Behavior Therapy (CBT)). Harnessing this truth that is hidden in plain sight is what gives so many of my clients the space to sit with discomfort and look inward rather than out. 

3. Pay attention to others and actually listen.

Counter to what I just mentioned above, 99% of our time spent with others is consumed by conversations about ourselves or distracted by social media. When you are in the presence of another human ask questions, dive in deep, and don’t be afraid to show your vulnerability. You will be AMAZED at how opening up about your insecurities can actually alleviate the drive for perfectionism. As I mentioned above, this is the ultimate paradox of anxiety. When we give in to this feeling of fear, self-doubt, and self-consciousness by admitting its grip to ourselves and eventually to others a powerful flip is switched. If perfectionism needs to be recognized, loved, seen, and worthy — stop trying so hard to get there. Lean into vulnerability with others and you will be returned with recognition and worthiness. 

Citations

Alden, L. E., Ryder, A. G., & Mellings, T. M. B. (2002). Perfectionism in the context of social fears: Toward a two-component model. In G. L. Flett & P. L. Hewitt (Eds.), Perfectionism: Theory, research, and    treatment (p. 373–391). American Psychological Association

Arlt, J., Yiu, A., Eneva, K., Drymam, M., Heimberg, R., & Chen, E. (2016). Contributions of cognitive inflexibility to eating disorder and social anxiety symptoms. Contributions of Cognitive Inflexibility to Eating Disorder and Social Anxiety Symptoms, 21, 30-32.

Roughly 2,000 years ago, the emperor of the Roman Empire sat in his tent to clear his head. He had plenty of reasons to decompress: ugly border disputes threatened his legacy, untrustworthy warlords schemed behind his back, and unrelenting family issues from the premature passing of his wife and a difficult relationship with his only surviving son brought on constant loneliness. Yet this emperor, Marcus Aurelius, remained mentally strong and became one of the most successful leaders in history. The secret to his achievements is distilled in the personal writings made in his tent far from home while de-stressing in the calm of night.

A classic figure of stoic philosophy, Marcus Aurelius promotes the development of mental self-control and fortitude by explaining, “the things that you think about determine the quality of your mind. Your soul takes on the color of your thoughts” (Aurelius, p. 67). In a world of intractable and fickle external circumstances, Marcus Aurelius highlights the significance of training our controllable thought patterns to overcome adversity.

Despite the rapid increase in knowledge of the natural sciences and specifically of mental health in the two millennia after Marcus Aurelius’ death, his stoic philosophy of using logic to identify and reconsider toxic beliefs and behaviors is more prevalent now than ever. This legacy lives on through cognitive behavioral therapy, or CBT. CBT is a pervasive evidence-based psychotherapy that assumes many of life’s problems derive from corrigible cognitions, feelings and behaviors. By recognizing the distress caused by maladaptive patterns in these three areas, one can work towards applying healthier, more practical responses to difficulties. Unlike in many forms of therapy, a CBT therapist works collaboratively with clients to set goals, identify problems and check progress, often through assignments between sessions. Clients learn to proactively break down problems into conquerable steps. Rather than dwell on the past, CBT focuses on specific, solvable issues in the present.

Also unlike many forms of therapy, CBT has extensive scientific research verifying its effectiveness. CBT facilitates research on patient outcomes by aiming to make quick, clear, measurable changes in thoughts and behaviors through fairly consistent procedures. One study examined 269 meta-analyses reviewing the overall effectiveness of CBT (Hoffman et al., 2012). Meta-analyses allow researchers to compile a range of studies, weigh their results based on the size and thoroughness of the research conducted, and draw comprehensive conclusions utilizing multiple data sources. This study went one step further by surveying many meta-analyses, thus providing a broad survey of contemporary evidence for the efficacy of CBT. The authors filtered results by quantitative analyses so that numerical comparisons between studies could be calculated, then filtered by recent results published after 2000. Last, the authors only included studies using randomized control trials, leaving 11 relevant meta-analyses. Randomized control trials are considered the gold standard in research because they meticulously determine whether a cause-effect relationship exists between treatment and outcome. The 11 studies showed better responses to CBT than comparison conditions in seven reviews, and a slightly lower response in only one review. Thus, CBT is generally associated with positive outcomes. However, despite the vast literature on CBT, many meta-analytic reviews include studies with small sample sizes, inadequate control groups, and lack representativeness of particular subgroups such as ethnic minorities and low-income individuals. Thus, the conclusions are insightful but complex. 

Not everyone benefits from CBT, which assumes that changing the processing of information leads to better behaviors. If a child has anxiety and ruminates about past experiences, jumps to extreme conclusions, or labels themselves in negative ways, they are likely candidates to benefit. But what if the problem is not so specific? What if the child has more complex issues like severe autism, and is unable to cooperate in therapy? Further research must be conducted to fully answer these questions. 

Some scientists argue that CBT focuses on obvious surface-level symptoms instead of the symptom’s deeper roots and consider this shortsighted since it reduces complex psychological and emotional states to simple, solvable problems. Can that reduction truly capture the subjective distress and complexity of the individual’s internal world? Perhaps not, but if therapy aspires to alleviate distressing symptoms, is it more helpful to understand the roots of patient’s internal world, or to focus on overcoming specific issues causing daily distress? Marcus Aurelius provided a simple metaphor to answer this question two centuries ago; “the cucumber is bitter? Then throw it out. There are brambles in the path? Then go around them. That’s all you need to know. Nothing more. Don’t demand to know why such things exist,” (Aurelius, p. 130).

CBT relies on parallel logic by concentrating on helpful and direct solutions to issues, rather than investigating their origins; perhaps this efficacy is why its lessons appear timeless. How to solve a problem overrides why the problem exists in the first place. Whether this is truly the best solution to mental health issues has yet to be determined. Nevertheless, the practical application of CBT, which originates in ancient philosophical rationality, continues to pervade.

Additional Resources

1. Cognitive Therapy in a Nutshell, by Michael Neenan and Windy Dryden: a detailed yet concise summary of CBT and its main tenants, accessible to readers untrained in counseling.
2. Happify app – available on mobile or tablet, this app offers engaging activities and games that help users identify negative automatic thoughts and tracks the progression of using positive emotions during information processing tasks.
3. Pinterest: by searching keywords such as “cognitive behavioral therapy” or “CBT,” this social media site provides useful images that can be saved for reference such as infographics and worksheets outlining CBT processes.
4. www.gozen.com: fun, animated cartoons to help kids learn the skills of mental resilience and well-being, including programs with games, workbooks, and quizzes

References

Aurelius, M. (2013). Meditations. Oxford University Press.

Hoffmann, S. G., Asnaani, A., Vonk, I. J., Sawyer, A. T., & Fang, A. (2012). The efficacy of cognitive behavioral therapy: a review of meta-analyses. Cognitive therapy and research, 36(5), 427-440.

One day, when my patient Brittany and David were meeting with me for a weekly session, the tension was so thick I could cut it with a knife.*

“What’s going on?” I asked.

Brittany started, “David said he’d be really safe when he went to the grocery store. He didn’t wear gloves, he didn’t put the bags on newspapers, and later he told me that he put some stuff on the counter without wiping it afterword. It was like COVID didn’t exist! It was really important to me, and he didn’t do it. To add insult to injury, he never apologized.”

“You told me to be extra careful,” David replied. “I went first thing in the morning and no one has touched anything since the day before, which is why I didn’t use gloves or newspapers. I don’t owe you an apology.”

I’ve seen this kind of scenario played out among couples in my professional practice and in my personal life among friends, family, and co-workers. Sometimes it’s been hard for me to apologize — so I’m not exempting myself from the need to do better.

Much has been written about forgiveness, but not much has been written about making apologies: When it’s offered for the wrong reason, why it’s hard to apologize, why some apologies are “non-apologies,” and how to make them properly.

When is an apology offered for the wrong reason?

We were taught to believe that we offer an apology because we did something wrong. But this simply is not the case.

If you walk in the aisle at a movie theater and you accidentally step on a stranger’s toes, what’s the first (and usually the only) thing you say? “I’m sorry.”

Mistakes happen, and because it’s dark and the aisles are close together, it’s bound to happen. So you didn’t intentionally do anything wrong, but you still apologized because you hurt the person.

And that’s exactly why we should apologize to the people we know. Any time two people are in a relationship — whether it’s a friend, spouse, or co-worker — it’s inevitable that you will occasionally hurt each other, regardless of how kind and well-intentioned you are. And apologies are meant to show others that you are sorry for hurting them.

Why is it hard to apologize?

When we’ve had a heated disagreement with someone, we can be much more reluctant to apologize, especially when we think we haven’t “done anything wrong.” Also, the emotions that come with an apology can be difficult to experience, and we often try to avoid them. So, refusing to apologize may be an attempt to manage your emotions.

Do you know that look that your dog gives you when you come home? When you just know that you’re going to walk into the next room to see ripped newspapers strewn all over the floor? Your dog’s head is hung, her tail is tucked, and her eyes say, “I’ve been a really bad dog, but I was bored and just playing around, so please don’t be mad at me!” If you’re a dog owner, you’ve probably seen this more than a few times.

Those feelings among humans (and maybe dogs too) are guilt and shame. A quick rule of thumb to distinguish between the two is that guilt is feeling bad for something you did, whereas shame is feeling bad for who you are.

Let’s say you texted your ex and your spouse is upset. That’s when you might become defensive by saying something like, “I wasn’t going to be rude by not replying.” Or you might make a counter-accusation by replying “That’s not fair. You’ve contacted your ex!”

You might not have done anything wrong, but you have hurt your spouse’s feelings, and he or she is owed an apology. So what is a true apology? To get at the answer, first consider non-apologies.

What is a non-apology?

A non-apology falls under four categories:

1. The half-hearted and excuse laden apology: “I guess I’m sorry that you were upset when I forgot your birthday. I didn’t mean to miss it, but I’ve been really stressed.”
2. The yes-but apology: “Sorry. I know I should have remembered to pick up the item you wanted at the store, but with the long line to get in and the one-way aisles and some people not wearing masks, I just forgot.”
3. The counter-attack apology: “I’m sorry for telling you to calm down when you were upset. You don’t have any compunction about telling me to calm down, and I don’t say anything.”
4. The “I’m sorry if”: “I’m sorry if I hurt your feelings.” This kind of non-apology blunts the impact and directness of a true apology.

How do you make a proper apology?

In the wonderful book, How Can I Forgive You? The Courage to Forgive, the Freedom Not To, author Janis Abrahams Spring focuses primarily on forgiveness, but she says for a true and full apology, you need to:

1. Take total responsibility for the hurt you’ve caused.
2. Identify what you did to hurt the other person’s feelings.
3. Make it about the other person and not about you.
4. Be specific and sincere.

Let’s say that you have friends that you can kid around with by calling each other names, but your partner has a sensitivity to name-calling. One day, you’re joking around with your partner and a bad name slips out. She’s insulted.

A true apology goes like this: “I apologize for calling you a name. I should have realized that would insult you. I was being insensitive, and I won’t do it again.”

If you continue to do it and apologize each time you do (think about the people in your life who repeatedly apologize for being late), it renders the apology meaningless. Instead, you have to decide to change your behavior.

But will you never do it again? Hopefully not, but because you’re human, sometimes stuff happens and, if you’ve gone a long time without a slip, your partner will likely forgive you if you humbly apologize and re-double your efforts.

What is the impact of a true apology?

A true apology can help you to be a better person, heal the wound of the person you wronged, and repair the relationship.
Regarding how it can help you, when you apologize, you might feel cleansed. When you have said or done something really hurtful, you can’t “take it back,” but by admitting it was stupid, insensitive, or unnecessary, you’ve put yourself out there and allowed yourself to make yourself vulnerable.

The cleansing can also lead to humility. As the saying goes, “to err is human.” It’s easy to become self-righteous, especially in a heated disagreement. By not apologizing, you’re missing out on an opportunity to gain some humility — a reminder that you’re a fallible human being.

The rest of the saying is, “To forgive divine.” But for the other person to fully forgive, what must come first is a sincere and humble apology. So, in regard to how it helps the person you’ve wronged, a true apology can lead to restoring trust and will go a long way to healing the wound you’ve inflicted. You are telling the other person, “You matter. Your feelings mater, and I care about you.”

David eventually realized that he hurt Brittany by ignoring her feelings. Because she has asthma, Brittany is terrified of catching the virus. David apologized, and he was more careful from then on.

Is there a person you’ve hurt yesterday or long ago that you’d like to apologize to? Think about how good it would feel to wrestle with your ego – that unyielding, stubborn, and self-righteous part of your psyche — and allow your best self to successfully emerge.

This in turn can lead to a better and deeper connection with the other person, which will naturally help the relationship. In this age of human disconnection, especially with the coronavirus, connection is the one thing we could all use more of right now.

*The names are fictitious and the story is an amalgam of patients.