Lisa Find Love

Codependency is more than a relationship problem. It’s a wound to our psyche and individual development. Make no mistake. It’s to no fault of our own. Codependency is adaptive and helped us survive growing up in a dysfunctional family system. But that adjustment costs us our individuality, authenticity, and our future quality of life. The beliefs and behaviors we learned then lead to problems in adult relationships. In fact, they tend to recreate the dysfunctional family of our past.

Origins of Codependency

Codependency is both learned and passed on generationally. It starts in childhood, usually because of codependent parenting, including being raised by an addict or mentally or emotionally ill parent. To survive, we’re required to adapt to the needs, actions, and emotions of our parents at the expense of developing an individual Self.

Repetitious patterning shaped our personality style with supporting beliefs, which were both learned and inferred from parental behavior. They were formed by our immature infant-toddler mind in the context of total dependency on our parents. An example is, “I must not cry (or express anger) to be safe, held, and loved.”

We developed a codependent persona, employing strategies of power, pleasing, or withdrawal to endure dysfunctional parenting. Appropriately using all of these is healthy, but codependents compulsively rely mostly on only one or two. In Conquering Shame and Codependency, I describe these coping mechanisms and personalities as: The Master, The Accommodator, and The Bystander. 

Pediatrician and psychiatrist Donald Winnicott believed that early childhood trauma threatens annihilation of the Self. It’s a disorientating shock that affects us on multiple systems. Trauma marginalizes thinking and impairs our ability to successfully achieve developmental tasks. Imagine a vulnerable infant having to overcome the threat of extinction while navigating interpersonal relationships, which should feel safe. He or she must be hypervigilant to anticipate and interpret parental reactions and adjust accordingly. Normal interpersonal development suffers. Instead, maintaining attachment becomes our priority while we still have to cope with ongoing relational trauma in childhood and later as adults. 

Hence, development of a fully-embodied Self is stunted by this system of accommodation. Effective parenting requires that parents see their child as separate individuals. They must attune to, empathize with, and honor their child’s experience. This allows us to feel safe and helps to develop an autonomous self. With codependent caregivers, we instead attune to them. We perversely organize our mental state to accommodate our parents. 

For example, how can a child navigate safety and fill his or her need for love with an inattentive, anxious, critical, or controlling parent? An anxious or abusive parent makes us anxious and fearful. A controlling parent extinguishes self-trust and initiative. A critical or intrusive parent squelches us, producing insecurity and self-criticism. These early patterns skew our perceptions of ourselves, our work, and our relationships. All of these and other dysfunctional parenting styles breed shame — that we’re bad, inadequate, and unlovable.

The Cost of Codependency

Early insecure attachments with caregivers necessitate that we sideline our spontaneous felt experience. Over time, as our personality and reactions solidify. Our ability to self-reflect, to process new information, to adjust, and to respond becomes impaired. Our reactions become rigid and our cognitive distortions feel absolute. 

Consequently, our individual development is hampered by the selective inclusion and exclusion of data that might provide conflicting information. We develop a template of “should’s” and restrictions that operate beyond our awareness. We do so because at an archaic, psychic level the alternative feels terrifying that we’d risk losing our connection to another person (i.e., parent) and people in general. In support of this, we project our parents’ reaction onto other people. 

For example, some of my female clients have impaired perceptions about their attractiveness and cannot be persuaded otherwise. A few may undergo unnecessary cosmetic surgeries, despite the consensus that they’re beautiful. Similarly, for many codependents, setting boundaries or asking for one’s needs feels selfish. They have a strong imperative against doing so, notwithstanding that they’re being exploited by a selfish, narcissistic, or abusive partner.

The Challenge of Recovery

The antecedents of our codependent personality are buried in our past. For many of us, it started in infancy. Some of us recall a normal childhood and aren’t able to identify what went wrong. Thus, our thinking and reactions go unquestioned and remain obstacles to learning from experience. Additionally, trauma’s effect on the nervous system makes it both difficult and frightening to uncover our feelings. Modifying our reactions and behavior feels perilous. 

We continue to behave according to the early system of accommodation that operates outside our conscious awareness. We’re guided by beliefs we never question, such as the common codependent belief, “If I’m loved, then I’m lovable,” and “If I’m vulnerable (authentic), I’ll be judged and rejected.” Moreover, we interpret our experiences in ways that fortify fallacious, archaic beliefs. An unreturned text confirms that we’ve displeased someone. This can even happen in therapy when we want to be liked by our therapist or fear his or her displeasure, boredom, or abandonment. A friend (or therapist’s) lapsed attention proves that we’re a burden and/or unlikeable. In intimate relationships, instead of questioning whether a partner meets our needs or is capable of loving, we conclude that we’re the problem. Our reactions to our misguided beliefs can perpetuate or escalate the problems we’re trying to remedy. We might unquestioningly repeat that pattern in subsequent relationships. 

Freud’s death wish is nothing more than a shame reaction to a punitive critic that rigidly spews out commandments that mimic an abusive or controlling parent or were developed as a child to avoid the terror of emotional abandonment. Our inner dictates crush our spontaneity and ability to experience the full range of our emotions, particularly, joy. When our normal reactions to parental behavior are frequently shamed, eventually, we can’t access them. We become numb and live an “as-if” life that covers up rage, despair, and emptiness. 

The Process of Recovery

We can heal our childhood trauma. In recovery, we learn missing skills, self-love, and healthy responses. Learning thrives in a safe, nonjudgmental environment, different from the stultifying one we grew up in that continues to dominate our mind. We need an atmosphere that welcomes experimentation and spontaneity where we can challenge the prohibitions embedded in our unconscious. Take these steps:

1. Seek therapy with a competent therapist.
2. Attend Codependents Anonymous meetings, and work with a sponsor.
3. Get reacquainted with your feelings and needs. This can be difficult process. Feelings live in the body. Pay attention to subtle shifts in your posture, gestures, and feelings, such as deflation, anger, guilt, anxiety, hopelessness, and shame. 
4. Explore triggers that shift in your mood and feelings and associated beliefs, thoughts, and memories.
5. Do the exercises in Codependency for Dummies and Conquering Shame to accelerate this process. 
6. Challenge your beliefs. See “Deprogramming Codependent Brainwashing.”
7. Write down and confront negative self-talk. Use the e-workbook 10 Steps to Self-Esteem to challenge your beliefs and inner critic.
8. Experiment, play, and try new things.

© Darlene Lancer 2020

I have experienced sadness and depression, and I know there is a big difference between the two. Even though I live with a diagnosis of schizoaffective disorder, sometimes I feel sad, and I recently began taking medication for depression. When I experience sadness, I drink more coffee, cruise the social network for something to inspire me, and I wish I had someone to ask, “What would you like to do on this lovely, Saturday?”

The last time I experience some depression, I was experiencing some suicide ideation for which, luckily, I did not have to be hospitalized. My psychiatrist, at the time put me on a low dose of an anti-depressant. 

My depression is a deep pool, and I cannot touch the bottom. I am about to sink, and I do not have a way to swim to the ladder or wall. I am surrounded by water and there is nothing or no one to rescue me. The faces of my family pictured on my office wall do not affect me. My mother’s pleas cannot break the wave of water about to swallow me whole. I must cry out for help. 

In 2013, I was hospitalized for my depression for which I had no control. I slept a lot. I could not put into words what I was feeling, however, my doctors understood. I hate being hospitalized, but that was the only way I could leave the ledge and my feet be on steady ground again. I realize now that my only way to save myself was to be hospitalized. Those doctors saved me, and I am grateful. 

The depression reminded me of a similar feeling I had in high school. My dad would say, “Jason, it seems like you have a dark cloud overhead.” I did not know how to explain how I felt. If it were not for my friends at the time, I might not have survived that troubled time. I thought life had no meaning, and life was mediocre. Life would not pick up, nor would I reach that peak of a satisfied life. Now I wonder if I was depressed rather than just sad.

In my early years of college, I was only motivated to work hard enough for an average grade. I was in the depths of a ditch that had no way out. The only thing I wanted to do was to drink alcohol and smoke cigarettes. I had heard of the word depression, but I thought I was just experiencing life. I thought life was hard for everyone, and I was just experiencing life like everyone else. If I could tough it out, I would get through.

About a year or so ago I was having some suicide ideation. I saw a vision of myself holding a gun to my head. I did not think I was conspiring against myself, but these thoughts gave me some concern, even though I did not own a gun. I did not always tell my doctors about my depression or suicide ideation, but that time I chose to do so. 

My diagnosis was schizoaffective, which is schizophrenia with a mood disorder, but surprisingly this was the first time I was treated for depression. My psychiatrist wisely prescribed an antidepressant for me. This turned out to be a huge moment for me.  As a result of being on the new antidepressant, I now catch myself in moments of pure happiness. Despite living alone, I am not overwhelmed with loneliness.

Sometimes I have moments of sadness that are different than my depression. Sadness can feel like tiny arrows pricking me throughout the day. Listening to music helps, and so does dancing. Yes, I dance with myself! Reading comments about the articles I have written about living day to day with schizoaffective disorder can also lift a sad moment and change it into something pleasant. Just the act of writing makes me feel better when I have had a sad thought.

Volunteering has been a way to distract me from sadness I might feel because I live mostly alone. I am the Chair of the monthly veteran’s council where I receive my medical resources and enjoy the idea that I am helping to give a voice and representation to those who might be overlooked by a large system. I also volunteer for the ShareNetwork which is a national volunteer group that allows people to share their personal stories as a way of helping others overcome their difficulties brought on by mental illness and other physical ailments. This does not only just make other people feel like they are not alone, but it makes me feel like I am not alone. The people who work for the share network treat me so well. We have become good friends. It is one of the best things I could have done for others as well as myself. 

I also exercise about six times a week. Exercise is particularly important for my daily routine. It erases the dark cloud over head and even lightens the negativity I might feel with sadness. I like writing the details of the workout I did for the day on a calendar. I do this because I like to see the progression of my workouts before I turn the calendar to a new month. I recommend to everyone to stay active, even if it is just walking around the block. Exercise is the best piece of advice I can give to anyone. 

It has taken me a while to learn that sadness is something that everyone can experience, even every day. However, depression is something altogether different. It is not just an emotion, but it can be attached to mental illness. Given my situation, I must be alert to periods of sadness that can lead to depression. I am glad my psychiatrist prescribed an antidepressant when I needed it. I can talk out sadness, but depression must be treated differently.

Nearly 80 years ago Isabel Briggs Myers developed a personality test she hoped would provide a constructive use of differences at a time when undemocratic regimes were disrupting the peace of the world. We are again faced with turbulent times that threaten our physical and emotional well-being, so it is fitting to describe how the Myers-Briggs Type indicator (MBTI) can again help clients and practitioners see the good in human nature through strengths based psychotherapy and bridging cultural diversity (Myers & Myers, 1980, 1995) in counseling.

Despite recent criticisms of the MBTI and psychological type theory (e.g., “False Portraits,” the article by Jennifer Fayard in the January 2020 issue of Psychology Today), the reliability and validity of its latest version (Form M) have been sufficiently established (Myers et al., 1998; Schaubhut et al., 2009). Furthermore, the MBTI type model provides certain advantages over the traditional trait approach to personality in counseling, in terms of promoting psychological growth and appreciating differences among people. 

Trait vs. Type

Academic psychology regards trait dimensional models of personality (especially the Five-Factor Model, FFM) as a given fact (Reynierse, 2012). However, FFM based trait instruments are not conducive to a positive constructive purpose in counseling, mainly because they generally consist of continua anchored with socially undesirable and socially desirable poles. In contrast, the MBTI points to preference dichotomies (e.g., Introversion or Extraversion, Intuition or Sensing, Feeling or Thinking, Perceiving or Judging) that are construed positively regardless of preference. The MBTI combines these preferences to form 16 psychological types that provide “portraits” for individuals with which to identify. 

Additionally, MBTI types can be contextualized (Hawkins & Meier, 2015) and applied at different levels of the person-environment context (person, dyad, family, group, career, community, nation, and worldview). 

A commonsense justification for typologies is that people naturally categorize the world, often in either/or fashion, and form stereotypes (Allport, 1954, as cited by Prince & Soper, 2019). As they obtain more information they refine these stereotypes through experiences with people who are different, and this familiarity reduces prejudice and increases understanding and liking. As a fictional example, many Star Trek episodes start with the Enterprise approaching a “Class M” (i.e., earthlike) planet, beaming down to the surface, encountering distrust and danger from the inhabitants, overcoming these obstacles, and finally accomplishing peace through which good qualities and values emerge and are acknowledged.       

For 40 years I have included the MBTI in my individual, couples, family, and group psychotherapy as a means for improving self-esteem and enhancing communication among people with differing psychological types, genders, and cultural backgrounds, in an approach akin to George Kelly’s (1955) “fixed role therapy”. In interpersonal contexts the client is invited to view others’ behavior and intentions through the lens of the 16 psychological types, appreciating differences in good faith rather than passing negative judgments. Used in this constructive way, the MBTI enhances my therapeutic alliance with my clients and helps to personalize evidence-based techniques in accord with the clients’ type preferences and values. The following example case study (adapted from Hawkins, 2000) illustrates this application of the MBTI and psychological type in the counseling context.   

A Case Study in Clinical Depression

Don, a 17-year-old Caucasian single male high school student, is being referred for individual and family counseling at the recommendation of his parents, former therapist, and his psychiatrist, for a major depressive episode (in partial remission) along with a history and current diagnosis of ADD (attention deficit disorder) and a possible social anxiety disorder.

Don’s mother has been worried about her son’s low grades, inattentiveness, decreased motivation toward school work, and “rebellious attitude.” This pattern is especially notable in Don’s English class, where he notes that “my English teacher worries about me and pressures me like my Mom, but in a more highly caffeinated way.” When his mother exhorts Don to study harder, he reportedly becomes more resistant, but also feels guilty and disappointed with himself.  

Don’s father is less concerned about his son’s school problems, as he describes having similar issues with inattentiveness and lower grades when he was in high school. Regarding Don’s relationship with his former therapist, he relates that he liked her because she gave him some concrete skills for coping with depression and did not “nag” him like his mother. Don disagrees with his female psychiatrist’s prescription of Wellbutrin, which he claims has not been helpful. He says he stopped taking this medication without informing his psychiatrist and has instead been experimenting with St. John’s Wort.  

Exploring the Role of Personality Type in Don’s Difficulties

The Myers-Briggs Type Indicator (MBTI) was offered to Don and his family to discover how some of his difficulties might be exacerbated by personality differences between Don and his family/social environment, and uncover strengths and positive motivations that would improve communication through the appreciation of these differences. Don and his family agreed to take the MBTI, with feedback and type verification provided separately, followed by a family consultation session (Finn, 2007) where the MBTI findings were discussed. 

Don’s reported preferred type is INTP (Introverted Thinking with Intuition). He strongly identified with the positive portrait of this psychological type, noting in particular that it mentioned computer science and website construction as possible interests, which Don endorsed as his major motivation in school. Don’s mother’s type preference is ISFJ. His father’s type is ENTP, and his brother’s type is INTJ. Don wondered if his parents’ MBTI types might explain why his mother worried about his school performance and future, while his father was less concerned, believing that he would “grow out of it” as Don’s older brother did. Don’s parents accepted the INTJ psychologist’s suggestion that the father work more closely with Don on his planning for college and participate with his son in their mutual interest in competitive running. In so doing the father would also help support his wife so that she would worry less about Don’s future. 

In subsequent individual sessions Don and I explored the possibility that psychological type might help explain how his social relationships were more or less challenging for him due to type matches or mismatches. For instance, his former female therapist (an ISTJ) was logical minded, which allowed Don to better accept her concrete, skill-building CBT homework assignments. His female psychiatrist (likely an ENFJ), on the other hand, was less logical in Don’s view, not debating with him the pros and cons of the antidepressant she told him to take. 

We also discussed other tools related to psychological type applications (e.g., the Murphy-Meisgier Type Indicator for Children, the Student Styles Questionnaire, and the Salter Environmental Type Assessment) that can be used to help accept and accommodate these differences. For example, with respect to his high school setting, which he described as “ESTJ”, Don said he could understand the logic for this structure, and would accept it if there was some flexible accommodation for his learning style. 

We estimated that his English teacher’s type may be ESFJ, which in combination with a subject where he has less interest, would mean that he would perceive her teaching style to be rote, “pushy” and less “logical.” This led us to more focus on Don’s subclinical social anxiety and his unassertiveness coupled with feelings of anger, guilt, and shame. INTP males are overrepresented among clients with social phobia (Hawkins, 1989), and are less interested in “feeling talk” and less skillful in social exchanges, particularly when interpersonal sensitivity and tact are needed for effective assertiveness. We role played these social skills, which he then used with his English teacher, his psychiatrist, and even with his mother. Consequently, he admitted that sometimes “feeling talk” can be useful, especially in forming relationships with potential dating partners. 

The Outcome

In this case study the client experienced numerous mismatches between his individual temperament and the available social environmental resources (Chess & Thomas, 1999). It is important for the therapist first to use the MBTI and similar instruments to reveal the matches and mismatches to validate the client’s understanding of himself and his world (i.e., discovering his “gifts”). Then can begin the second task of helping the client appreciate and value these differences without passing judgment on self or others. This process is an ongoing bridging of differences by seeing their complementary nature (Kelso & Engstrom, 2006). Just as Kegan (1994) offers the visual gestalt shift from seeing the two holes at the ends of a tube to appreciating the “whole” tube that links the two ends, the MBTI framework, applied at different contextual levels of the social ecological system, provides a strength-based framework to complement the usual problem-focused approach used in clinical psychology.

In this model the effects of the mismatches with both his parents’ psychological types, the “bureaucratic” school setting, his social avoidance and his limited social support failed to ameliorate depression, social anxiety, and personal/social alienation. However, through the individual and family treatment (12 individual sessions, plus two family consultation sessions) Don was able successfully to graduate from high school with several advanced placement classes under his belt, was accepted into a computer science program at a prominent university, and is doing well at the end of his freshman year.

References

Allport, G. W. (1954). The nature of prejudice. Reading, MA: Addison-Wesley.

Chess, S., & Thomas, A. (1999). Goodness of fit: Clinical applications from infancy through adult life. Philadelphia, PA: Brunner / Mazel.

Fayard, J. (2020). False portraits. Psychology Today, January 2020 issue. https://www.psychologytoday.com/us/articles/201912/false-portraits.

Finn, S. (2007). In our clients’ shoes. New York, NY: Routledge.

Hawkins, R. C. II. (1989, August). Psychological type and anxiety disorders: Preliminary findings. Paper presented at the annual convention of the American Psychological Association, New Orleans, LA.

Hawkins, R. C. II. (2000, March). Using the MBTI and SSQ in family counseling with teenagers with Attention Deficit Disorder. Paper presented at CAPT Fourth Biennial Education Conference, Gainesville, FL.

Hawkins, R.C. II, & Meier, S.T. (2015). Psychotherapeutic theories of change and measurement: An integrative model. Journal of Unified Psychotherapy and Clinical Science, 3(1), 80-119.

Kegan, R. (1994). In over our heads. Cambridge, MA: Harvard University Press.

Kelly, G.A. (1955). The psychology of personal constructs. New York, NY: Norton.

Kelso, J.A.S., & Engstrom, D.A. (2006). The complementary nature. Cambridge, MA: MIT Press.

Murphy, E., & Meisgeier, C. (2008). A guide to the development and use of the Murphy-Meisgeier Type Indicator for Children. Gainesville, FL: CAPT.

Myers, I.B. & Myers, P.B. (1980, 1995). Gifts differing. Palo Alto, CA: Consulting Psychologists Press.

Myers, I.B., McCaulley, M.H., Quenk, N.L., & Hammer, A.L. (1998). MBTI Manual: A guide to the development and use of the Myers-Briggs Type Indicator (3rd ed.). Palo Alto, CA: Consulting Psychologists Press.

Oakland, T., Glutting, J. J., & Horton, C. B. (1996). Student Styles Questionnaire: Star qualities in learning, relating, and working. San Antonio, TX: Pearson Associates.

Prince, A., & Soper, H.V. (2019). Development of prejudice. In: Soper, H.V., & Gaines, K.D. (Eds.), Hidden cultures in clinical psychology. Fielding Monograph Series, Volume 13. Santa Barbara, CA: Fielding University Press.

Reynierse, J.H. (2012). Toward an empirically sound and radically revised type theory. Journal of Psychological Type, 72(1), 1-25.

Salter, D. W. (2000). SETA manual: A users’ guide to the Salter Environmental Type Assessment. Palo Alto, CA: Consulting Psychologists Press.

Schaubhut, N.A., Herk, N.A., & Thompson, R.C. (2009). MBTI Form M: Manual supplement. Palo Alto, CA: Consulting Psychologists Press.

Events are traumatic when they are highly stressful, frightening, or distressing. Such experiences can inflict deep psychological wounds, damaging our mental health and reducing our overall sense of wellbeing.

That being said, could there be a silver lining to trauma?

To even pose the question can seem insensitive to those who have suffered, or are suffering, acutely. Still, while the costs of trauma are well-documented, less consideration has been given to the counterintuitive possibility that trauma might contribute positively to our wellbeing in particular ways. And given that nearly all of us will experience traumatic events over the course of our lives, this is surely a possibility worth exploring — particularly if there’s a chance we can help realize any potential upsides through our reactions to trauma.

Before considering whether traumatic events can make any positive contributions to our wellbeing, we should take a moment to consider what we mean by “wellbeing”. While no universally agreed definition exists, most theorists agree that wellbeing is multidimensional; in other words, that it is made up of different parts, encapsulating much more than just feeling good.

One influential conception of wellbeing is offered by Martin Seligman (2011), the main pioneer of Positive Psychology (the subdiscipline of psychology which studies the conditions of human flourishing). According to his PERMA model, our wellbeing is built from the following five components:

• Positive emotion
• Engagement
• Relationships
• Meaning
• Accomplishment

Towards which component of wellbeing might traumatic experiences contribute something positive? According to research by Sean Murphy and Brock Bastian (2020) at the University of Melbourne, the answer could well be meaning; the foundation of wellbeing enhanced when our life and experience is felt to serve some higher purpose. In a series of online studies, they sought to test the hypothesis that whether an event is felt to be meaningful is not a matter of it being positive or negative, but the extremity of emotion it evokes.

Though this question had not been directly investigated before, there are good grounds for suspecting that, for meaning, extremity of emotion matters more than valence (i.e. whether emotions are positive or negative).

It is easy to see why events that produce extremely positive emotions could give a sense of meaning. Moments of profound awe, connection to others, and great inspiration represent peak experiences that help shape our life narratives. Times of great distress, grief and fear are less obviously suffused with meaning. Nevertheless, there are reasons to think that people might ultimately construe even extremely negative experiences as meaningful.

Traumatic events can challenge our understanding of the world in profound ways (Park, 2010). They may, for instance, cause us to revaluate a belief that life is fair, or that everything happens for a reason. This can bring about major transitions in our outlook that, once gained, we would not wish to lose. Perhaps for this reason, we often see traumatic events as influential to our personal development; as times when we may have discovered a new side to our self, such as a depth of resilience we never thought we had, or expanded our understanding of the world around us.

There are also characteristics shared by extremely positive and extremely negative events which give the potential for meaning. For example, where events create intense emotions, we tend to accord them significance, whether positive or negative (Fredrickson, 2000). Significant events are those parts of our life stories that stand out, naturally imbuing them with a sense of meaning.

Extremely positive and negative events also share a tendency to bring people together. Where traumatic events are concerned, this can either be because our trauma is shared with others, or because others rally to our aid in our hour of need. Great bonds of camaraderie can be forged in the furnace of traumatic experience.

Finally, research shows that all extreme emotions tend to induce contemplation (Rimé, Philippot, Boca, & Mesquita, 1992).  Often this means contemplating how an emotive event, and the circumstances surrounding it, connect with our deeply held values. This can increase the significance of the event to our life narratives.

To test the hypothesis that emotional extremity, rather than valence, is what leads us to see events as meaningful, Murphy and Bastian (2020) asked a sample of Americans to think of two events in their own lives occurring within the past year: one which produced extremely positive emotions, and one which produced extremely negative emotions.

They also asked their participants to rank:

• How meaningful they felt each event to be.
• The intensity of the positive or negative emotions they felt in response to each event.
• To what extent these experiences had increased their connection to others.
• How much they had since contemplated these positive and negative events, respectively.

When they crunched the numbers, the researchers found that, as expected, events evoking extreme emotion were more likely to be considered meaningful. Crucially, it made no difference whether these extreme emotions were positive or negative.

They further found that this relationship between emotional extremity and meaning depended on:

1. The intensity of emotions felt, with greater meaning attributed to events that produced very intense emotions.
2. The degree of contemplation sparked by an event, with more contemplation associated with a greater sense of meaning.

It is important to say that because these findings are correlational, we cannot say for sure that extreme emotions caused the sense of meaning participants reported, even if there are good reasons to think this likely. It could be that people more prone to extracting meaning from experience in general are also more susceptible to feeling extreme emotions. Nevertheless, the findings do point to the possibility that traumatic events offer something of potential value in addition to the pain they cause.

The fact that study participants found their emotive experiences to be more meaningful the more contemplation they had given them suggests we have some agency in obtaining meaning from our trauma. By reflecting on what lessons a traumatic event could teach us, or its importance to the story of how we came to be who we are, we may be able to reframe the event as something meaningful, without having to deny the pain it caused or is causing.

Traumatic experiences are not something any of us desire, but they are something few of us will be able to completely avoid during our lives. It is reassuring to think that we could, in time, distill meaning from our hardship, shift our focus from what was lost to what was gained, and reclaim something affirmative to our wellbeing in the process.

References

Fredrickson, B. L. (2000). Extracting meaning from past affective experiences: The importance of peaks, ends, and specific emotions. Cognition and Emotion, 14(4), 577–606.

Murphy, S. C., & Bastian, B. (2020). Emotionally extreme life experiences are more meaningful. The Journal of Positive Psychology, 15(4), 531-542.

Park, C. L. (2010). Making sense of the meaning literature: An integrative review of meaning making and its effects on adjustment to stressful life events. Psychological Bulletin, 136(2), 257–301.

Rimé, B., Philippot, P., Boca, S., & Mesquita, B. (1992). Long-lasting cognitive and social consequences of emotion: Social sharing and rumination. European Review of Social Psychology, 3(1), 225–258.

When I was 14 years old, I entered my freshman year of high school feeling nothing but a dull sense of disquietude. I was not happy to be starting the new school year. I was always “the quiet kid”, and that label only rang truer over time, as I retreated further into my shell with each passing school year. I had few friends, and the ones I had were fair-weather, frequently passing up hanging out with me in favor of others. I knew in the back of my mind that I should feel stressed or upset when the year began, but I just felt empty. 

My late childhood and early adolescence, meant to be a time of growth and learning, instead left me emotionally stunted. My stepfather was dying from congestive heart failure, the organ covered in scar tissue from the multitude of heart attacks he had suffered over the previous several years. He had ignored the advice and warnings of several doctors along the way, worsening his condition. My home no longer felt like a safe haven with the presence of death constantly looming. 

The lack of oxygen going to his brain and his constant feeling of general malaise cut his already short fuse down to nothing. You could not have a conversation with him for fear he would snap at you, and when he wasn’t in the hospital he barely left his bedroom. He was a husk of his former self, a bitter man consumed by sickness and regret. Every day my mother and I wondered if it was his last. As guilty as I felt for feeling this way, he was an unwelcome presence in my home. I do not think of sick people as intrusions and I know he was suffering greatly, but with the way he spoke to my mother sometimes, I could not help but feel resentment.

I was not comfortable at home, and school was certainly not an escape from stress. I had nowhere to turn, and no sense of reprieve. 

You expect to feel a certain way in response to trauma. You expect to cry frequently and have difficulty with your everyday tasks. However, instead it felt like my brain was full of TV static. 

I floated through my days in a dreamlike state, days blurring into one another. My life felt like an endless slog, each day as equally grating and unimportant as the previous one. I did not care about my subjects in school; I did my assignments on autopilot and would only speak when spoken to. Colors appeared less vibrant and my vision was hazy. The world around me and the body I was in felt foreign. Sometimes when I saw my own reflection I would barely recognize myself.

I didn’t know exactly when this detachment from reality had come to be, as I was slow to notice it happening at all. I knew that I used to feel things more deeply, and then one day, I no longer did. I didn’t give much thought to my surroundings, but over time I had a creeping realization that the ineffable connection between myself and the world around me had been severed. 

I was easily confused, my memory was spotty, and some days I was barely able to form a coherent sentence. My trains of thought were frequently derailed. I felt as though my mind was buried in a dense fog, keeping me from finding the proper words for what I wanted to communicate, forming logical connections, and digging through memories. I simply could not concentrate on anything. I had unexplained headaches and hand tremors. Distantly, I wondered if I had a brain tumor, but did nothing to investigate, even though on some level I believed it was a distinct possibility.

There were times when I thought I was going insane. I felt like I was trapped inside a body I did not recognize, forced to play the role of student and daughter in a farcical world, a cheap stage set that seemed to fool everyone but me. I understood on a fundamental level that my surroundings were real, but my physical perceptions and dampened emotional reactions seemed to indicate otherwise. No stimuli, no words, no information or person could elicit an emotional response naturally; I had to play pretend. Sad stories and events had almost no effect on me; I could not cry even if I tried. Life felt like a sick joke, and nothing mattered to me anymore. 

Back then I thought I was just “crazy” and alone in my experience. However, I later learned that these disorienting, alien sensations were not a sign of my mind unraveling. I was experiencing depersonalization coupled with derealization — a condition that I was surprised to find is not uncommon. I now think of it as my brain’s best attempt at coping with my circumstances, despite how unsettling it felt at the time.

A 2004 review by Hunter et. al. of then-current studies on depersonalization described the experience in a way that resonated with me, as it was so accurate to what I went through: the authors discussed a “dream-like state” in which the sufferer may feel a “loss of empathy and a sense of disconnection with bodily parts” to the point that one feels “as though they are observing the world from behind glass.” They pointed out that depersonalization is often accompanied by derealization, “in which the external environment also appears unfamiliar, with other people appearing as though actors and the world appearing as if two-dimensional or like a stage set” (p. 9). As I was scared to go to therapy and face my problems head-on, I spent many nights as a young teenager Googling my symptoms. Seeing my exact experience written about by clinicians and discussed in online forums made me feel less alone, and reading about its prevalence validated me further.

Clinically significant feelings of depersonalization can occur as a primary disorder (Depersonalization/Derealization Disorder), but often present as part of an array of symptoms related to a mental illness such as depression or anxiety (Michal et. al., 2011, p. 106). Depersonalization can also be triggered in response to trauma as in my case. While feeling detached from reality for an extended period of time is not considered normal, transient experiences of depersonalization are fairly common even in healthy individuals, particularly in states of high anxiety or sleep deprivation. Multiple studies have investigated the prevalence of these symptoms during traumatic events, reporting rates “varying from 31% to 66%” (Hunter et. al, 2004, p. 11). A more general “lifetime prevalence rate” of these experiences has been recorded as “between 26% and 74%” (Michal et al., 2011, p. 106). 

As I became more aware of my symptoms and had a prospective name for them, I found myself scared of my own physical body. I would stare at my hands until it hit me that they belonged to me, and I occupied a physical space in the world, and I was real. The thought sent a jolt of fear through me, as it forced me to realize with jarring clarity how truly disconnected I was from myself.

Baker et. al. (2007) described how depersonalization can cause anxiety if a person experiencing it is hypervigilant of their symptoms and worries excessively about them, considering every tiny change in their mental or physical state as a sign of their condition worsening. Symptoms of depersonalization may be “misinterpreted as indicative of severe mental illness or brain dysfunction” and hypervigilance may cause “a vicious cycle of increasing anxiety and consequently increased sensations” (p. 106). I thought I was broken inside; irreversibly damaged. Of course, that wasn’t true.

When I was 16, my stepfather passed away, and I felt as though I had sunk to the bottom of the ocean; my surroundings and emotions were muffled. Rather than dealing with my sadness right away, the emotional blowback came in flashes over the course of months. There were days when I was immobilized by the weight of it all, surrounded on both sides by months of complete numbness. 

I gave in and began going to therapy so I could come to terms with how my brain worked. What helped the most, though, was simply time. I was able to distance myself from my bad memories and cope with them as time passed, especially once I graduated high school. My symptoms improved slowly but surely over the course of a couple years, gradually returning color and vitality to my life. I noticed that I felt better overall, but whenever I became stressed or was reminded of my past trauma the barrier between myself and my surroundings returned. 

Now at 23 years old, symptoms of depersonalization show themselves when I am anxious, but they are less constant and never as severe as they were at when they first started. These feelings do not scare me as much, as I know I am not “broken”, or going insane, or dealing with a threat to my safety. Acceptance of my symptoms actually decreases their severity and helps me focus on the underlying stressor causing them. My experiences are a part of me, but I try not to let them hold me back, though some days that is easier said than done.

References 

Baker, D., Earle, M., Medford, N., Sierra, M., Towell, A., & David, A. (2007). Illness perceptions in depersonalization disorder: Testing an illness attribution model. Clinical Psychology & Psychotherapy, 14(2), 105–116. https://ift.tt/3i85q8G

Hunter, E.C.M, Sierra, M., & David, A.S. (2004). The epidemiology of depersonalization and derealization. Social Psychiatry and Psychiatric Epidemiology, 39, 9-18. https://ift.tt/3kitJTh

Michal, M., Glaesmer, H., Zwerenz, R., Knebel, A., Wiltink, J., Brähler, E., & Beutel, M. (2011). Base rates for depersonalization according to the 2-item version of the Cambridge Depersonalization Scale (CDS-2) and its associations with depression/anxiety in the general population. Journal of Affective Disorders, 128, 106-111. https://ift.tt/31onu7G

Anxiety. Everyone is feeling it during the pandemic. Anxiety about the virus, anxiety about going places and not knowing how safe it is due to the virus, anxiety about the economy, anxiety about paying rent or medical bills when finances have been impacted by the virus, anxiety about sending kids back to school, anxiety about dating during the pandemic, anxiety about missing out on experiences, anxiety about the future, anxiety about having anxiety! Did I name yours yet?  

As an expert in treating anxiety, I’ve seen the spike in anxiety caused by the pandemic for my clients, my friends and family and neighbors, and at times for myself as well. Anxiety is part of being human: it is our fight-flight-or-freeze reaction that evolved as a survival instinct, to help us avoid or defeat serious and immediate threats to our safety.  That instinct was meant to trigger a burst of energy (cortisol, a stress hormone, which tells us to “hit the gas”) for a short window of time for us to get to safety. It wasn’t meant to be a way of living and feeling day to day; staying in fight-or-flight state for extended periods wreaks havoc on our bodies (messing with our digestion, decreasing sleep or sleep quality, compromising our immune system), our mental capacity (our executive functions like focus, memory, decision-making and planning), and our ability to cope (regulating emotion, mood, behavior).

In most of my work pre-pandemic, I taught people to recognize their survival instinct turning on and staying on when it wasn’t necessary — while getting stressed is normal and can be motivating, getting highly anxious in scenarios like public speaking, test taking, and socializing can be counter-productive, embarrassing, and limiting for our potential. My job was helping people over-ride and turn off their “panic button.”

Anxiety, as well as anxiety treatment, during the pandemic is a bit different. Your brain is not wrong to think that there are dangerous threats lurking around the corner in your current environment or near future. There are real threats right now to our physical safety, our financial stability, our children’s social and academic development, and our mental and emotional well-being. The challenge is not to eliminate the fear that we are feeling, as we would treat a phobia by eliminating the fear of a test or public speaking or entering a group conversation. The challenge in coping with anxiety in the pandemic is to be okay, right here and now, in spite of real fears and real obstacles. To be able to be calm amidst threats.  

Coping with anxiety during the pandemic is about being present, mindful, courageous, and compassionate.  We must be present because thinking into the future is uncertain and can be scary, while the present is usually okay enough for us to feel okay. We must be mindful in order to keep ourselves in the present — catching ourselves when we start to dread or overthink things, shifting our focus to present experiences. We must be courageous to mindfully notice our fear and yet still choose to focus on the here and now and try to enjoy it.  And we must be compassionate with ourselves and each other because courage in the face of this fear is hard, mindfulness takes practice, and being present can be truly challenging — so we have to be kind as we fumble through the process. Here is how: 

• Be Present: The present is where we have control of our choices and actions, and where we can enjoy positive experiences if we choose to do so. You can practice pulling yourself back into the present in different ways throughout your day. Choose activities during your day to “tune in” as much as possible — turn off the phone, have the goal in mind that you are going to be present, and focus on your five senses and what you are experiencing in that moment. That can be eating a meal, taking a walk, or even brushing your teeth. In the moment you are doing something, think only of that thing and chances are that it feels okay: there isn’t anything painful or scary about brushing your teeth right? Eating something delicious is enjoyable, right? When you focus your attention on what you are doing and feeling in that moment then you can start noticing feeling and being okay. And if you can notice being or feeling better than okay, by tuning in to more positive experiences than just tooth-brushing or eating — well that’s even better! If it is tough staying present though, start with these small moments. Some of my clients who struggle with feelings of panic find comfort in reminding themselves, “In this _______ (moment, 10 seconds, breath, minute, hour, activity) I am safe, I am okay.”
• Be Mindful. Being present is a big part of mindfulness, and practicing mindfulness will help strengthen your ability to be fully present. If you are looking to start a mindfulness practice, pick whatever practice you will actually stick to: could you use Headspace app every day for a month? Could you watch a short guided meditation on Youtube three mornings a week, keeping it on your google calendar as a reminder? Can you meditate before you fall asleep three nights a week or more, using the Peaceful Place Meditation (see instructions here)? Would you listen to a meditation from tarabrach.com (highly recommend — she is wonderful) once a week? Choose ONE practice you will stick to, and incorporate it into your daily or weekly routine — your mind needs this as routine hygiene the same way you need to brush and floss and shower.  Know that you might not feel relief or relaxation the first time or the first ten times that you do this — you don’t lose weight your first time on a treadmill either, it actually might be pretty uncomfortable at first. This is a “If you build it (your mindfulness practice), they (calm feelings) will come” type of deal that takes a lot of repetition, but research shows the massive payoffs for your brain and your mood in as short as 8 weeks. In as little as 2 weeks, my clients notice feeling calmer, having an easier time meditating for longer, and having less distress in response to triggers.
• Be Courageous. Choosing to be present, and practicing mindfulness to get better at staying present, is a courageous thing to do in the face of a TON of uncertainty and fear. Your anxiety is your survival instinct telling you to actively do something to get away from danger, so the urge is to worry, fixate, obsess, check the news, lest you might forget about the threat and then lower your survival chances. The courageous choice here is to bravely tune out the threat — to notice the anxiety but ignore your own instincts and trust that it will be ok to do this, in order to take back control of your own nervous system and access your experiences in the present. This is hard work! The good news is: We can do hard things! Think back to a time that you did something hard even though it was scary or painful — maybe pushing through running a marathon, or your first day at a new job, or maybe it was recently going somewhere public with a mask on even though you felt scared. Notice how it felt to use your courage, and know that this courage is a resource you have used so many times already in your life — it’s in there, ready for you to use it now, and you’ve already been using it some to get through your daily life since the pandemic started.
• Be Compassionate. Did you just read my paragraph on courage and think to yourself, “But what if I can’t ignore my anxiety? What if I’m not courageous?” That’s okay. All of it — everything you’re feeling, the good, the bad, the courage, the anxiety — it is all okay. You are human and you are trying your best so be kind to yourself. I tell my clients often to think about their self-talk. If you’re in the middle of a soccer game and you’re getting exhausted, do you want your teammates and fans yelling at you, judging you, or shaming you? Of course not. You want encouragement. Some people prefer direct advice and tough love from the sidelines, while others want gentle and affectionate soothing words, but all people need to feel encouraged because we need connection and a belief in ourselves in order to overcome challenges. That encouragement can come from your own inner voice. Your self-talk, when you’re struggling, should sound like the kind of encouragement you most like to hear in order to feel connected and to believe in yourself. Mine sounds direct like this: “I’ve got this. I can handle this. This situation/this feeling is temporary. I can do hard things.” What does yours need to sound like? Start practicing it with yourself, and while you’re at it you can practice on your loved ones, too.

You’ve got this. You can handle this. You can do hard things. You already possess all the strength and courage that you need in order to manage your anxiety through this awful time; with practice, patience, and self-compassion, you can feel better.  And support is here if you need it — therapy is a great way to connect with your inner resources when going through a challenging time.

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.