Things I’ve Learned About Trauma
As a trauma therapist, I love continuing to read up on new research as well as learning from established experts. Here are some of the things I’ve learned or re-learned over this past year. The books and courses are listed in the headings so you can reference them if you’re interested.
Gabor Mate: The Myth of Normal
This book focuses on trauma as a natural response to a toxic culture and its social structures, belief systems, assumptions, and values. As toxic culture generates chronic stressors, the incremental shifts into ever-increasing stress become normalized. This normalization prevents us from recognizing that we’re stressed out both mentally and physiologically until we fall apart “out of nowhere” from the buildup of stress.
He defines trauma as “not what happens to you but what happens inside you”. While trauma can definitely be our response or adaptation to a specific, identifiable hurtful or overwhelming event, this definition expands our idea of trauma. He includes the everyday, seemingly ordinary events of life that create inner injuries, ruptures, or splits. This can look like bullying and lack of emotional connection, bad things happening and good things not happening, or even a disconnection with self due to unsatisfied core needs.
The core symptom of trauma, then, is a separation from the body. This separation is a natural response to pain without relief. But it also results in a separation from our instincts, gut feelings, and ability to respond flexibly.
Treating Relational Trauma with EMDR
Trauma affects us in many ways:
internalized experience
lack of safety
physical responses
questioning and comparing
memory intrusion
EMDR primarily targets our perceptions and belief systems that allow us to make meaning from what happened and what we experienced. Repair to meaning making helps heal the experience and impact by bringing us back to a healthy perception of self.
Relational trauma harms our identity and sense of self, our ability to feel safe in relationships, our ability to feel safe in the world, our attachments to others, our ability to trust in ourselves, and our trust in our body instincts.
Body/brain disconnection, dissociation, and desensitization make our body instincts feel threatening. Our natural response to threat is to numb and shut down. Disconnection allows us to survive trauma. It’s safer to shut down our insight and awareness than to stay connected to a painful experience.
Symptoms of disconnection:
difficulty feeling present or alive
being easily upset or startled
stomach aches, IBS, autoimmune disorders
lower immune functioning
difficulty trusting self and others
internalized responsibility for things not linked to you
disrupted sleep patterns
increased heart rate
difficulty concentrating
changes in vocal pitch
emotion swings, mood swings
intolerance of self and others
shaming, hopeless, and unchanging narratives of life
We have two basic needs: survival and connection. Safe, connected relationships create a space where our brains can develop well and function normally. Trauma literally disrupts our brain development and hinders our psychological and emotional well being.
Trauma lowers left brain activity which is our logical, problem solving, concentrating, and organizing hemisphere. It also increases right brain activity which is our mirroring, emotional, experiential, meaning making hemisphere.
This disruption affects our internal working model of ourselves, others, and the world. Read through these questions and see how you feel:
Am I worthy of attention and love?
Am I good enough?
Am I safe here?
Are others trustworthy?
What support can I expect from others?
How do relationships work?
How safe is the world for me to explore?
How curious am I about how the world works?
How confident am I to explore the world on my own?
Somatic and Sensorimotor Sequence of Trauma
We have three responses: hyperarousal, hypoarousal, and dissociation. Everyone has a primary response but we’re capable of using all three. In trauma therapy, we’re looking for any of these responses causing problems in our day to day life. We have different responses to our experiences as we try to protect ourselves, prevent pain, and make meaning of the experience.
Hyperarousal is our anxiety, irritability, difficulty concentrating, hypervigilance, impulsivity, and tension. Hypoarousal is our disconnection, slow response, shut down emotions, depression, and low energy. Dissociation is our daydreaming, detaching, checking out, and avoiding.
Somatic attention to trauma is important because our bodies often hold trauma memory below our conscious experience. Our subconscious memories have a huge impact on our physiological responses to perceived threats. We may not know exactly what it was that was triggering, but we can learn to recognize when our bodies are responding to a threat in our environments.
Somatic work allows us to navigate both types of memory. Our implicit, subconscious memory is procedural and emotional, affecting our instincts and habits as well as our emotional associations. Trauma here looks like somatic symptoms, triggers, and a feeling of emotional charge. Our explicit, conscious memory collects and combines experiences and helps us put them in a sequential episodic narrative. Trauma here looks like a memory disconnected from sense and sequence, a feeling like the past emotional experience is still present.
Theories of EMDR and How it Works
EMDR is an evidence-based psychotherapy for PTSD. Successful outcomes are well documented in the literature for EMDR treatments of other psychiatric disorders, mental health problems, and somatic symptoms. The model of EMDR is based on Adaptive Information Processing (AIP), which believes that much of psychopathology is due to the maladaptive encoding and/or incomplete processing of traumatic or disturbing adverse life experiences. This impairs the person’s ability to integrate these experiences in an adaptive manner. The eight phase, three prong (past, present, future) process of EMDR facilitates the resumption of normal information processing and integration. The treatment approach targets past experiences, current triggers, and future potential challenges. It results in the alleviation of presenting symptoms, a decrease or elimination of distress from the disturbing memories, improved view of the self and relief from daily disturbances, as well as a resolution of present and future anticipated triggers.
—EMDRIA official definition of EMDR
Three currently predominant theories of why EMDR works:
Beating and drumming are used for healing in many rituals across cultures. Rhythm is a naturally calming remedy, possibly connected to heartbeats in utero. The bilateral stimulation of EMDR taps into our self healing capability.
REM cycles appear to help consolidate memory. Studies show similar mechanisms with bilateral stimulation that allow us to reprocess and re-encode stuck trauma memories that were improperly stored. We know that a loss of REM sleep affects our memory and ability to make associations which is similar to how trauma affects those same systems.
The working memory hypothesis posits that bilateral stimulation works because bilateral stimulation disrupts working memory by activating both sides of the brain. Disruptions in working memory encourage those active (and activating) memories to store properly in our long term memory.
EMDR is a very internal process. As the client, your job is to simply pay attention to what is happening in your mind and body. The therapist is a guide, companion, and facilitator to help orient you and ensure that your trauma doesn’t bring you out of your window of tolerance.
Attachment in Trauma Treatment
Therapy is a corrective emotional experience, and every session is a safe adventure. The goal is to create a secure sense of order in your internal world. Where trauma creates disorganization and disorder, attachment organizes and balances. In therapy, we attune to each other, hold space for your experiences, and heal the emotional imbalance.
In order to create a secure attachment space where you can heal, you need a safe haven attachment figure who provides an accessible, responsive, and engaged presence. Positive, secure interactions create new mental models that allow for a new sense of safety and security alone and in relationships. Having emotions and co-regulating with a safe person allow for us to have these corrective experiences.
Traumatized people have emotional disorders due to disordered attachment. We all want to be fully alive, resilient, secure, and coherent. Connection is a primary human need. Aloneness leads to a trauma response cycle, and feeling vulnerable escalates trauma symptoms. We’re healing your brain and its functioning, so the work can feel slow and low since that’s what your mind and body need.
Secure attachment allows us to acknowledge our needs, send clear and coherent messages to others, reach out, accept care, and give care.
Anxious attachment feels like a fight response, hyperarousal, hypervigilance, and high needs.
Avoidant attachment feels like a flee response, hypoarousal, and minimized needs.
Fearful attachment flips between approaching and avoiding as it finds both comfort and fear from others.
Importantly, attachment wounding is not just from abusive parenting. It can happen in response to any inappropriate caregiver response to your needs. Inappropriate here means a response that doesn’t meet your need on an ongoing basis that changes with you.
Attachment wounds generally show up from disruptions when you are 0-5 years old. While they may certainly come from abuse, they also come from smaller, repeated separations when your caregiver is absent, preoccupied, managing their own issues, or not equipped to handle your needs well.
Children need co-regulation from caregivers until they learn to regulate themselves. Trends in parenting advice have lead to a wide variety of information on how to parent that are conflicting and confusing for parents who are simply trying to do their best.
Trauma is inherently subjective, an autonomic response outside of our conscious volitional control. As a result, we may be carrying early traumas from attachment wounds even from things we may consciously recognize as rational or normal from an adult perspective.
Understanding Complex Trauma from a Neurobiological Lens
Trauma and stress are protective responses to times of overwhelm or threat that were never resolved. Our enduring reactions show where the stuck places still catch our current response patterns.
Everyone goes through traumatic experiences, but not everyone develops PTSD or C-PTSD. Our normal response to trauma includes irritability, anger, fear, panic, sadness, numbness, shock, shakiness, nausea, dizziness, and other similar psychological and somatic reactions. For most people, these responses will regulate themselves with time.
Core symptoms of PTSD or C-PTSD go beyond this normal response:
Re-experiencing symptoms and somatization, possibly on a sensation-based level
Avoidance, including withdrawing, isolating, excessive sleeping, using substances, perfectionism, and self-criticism
Heightened arousal, high consciousness of others, planning for possible outcomes
Difficulty with affect regulation and long recovery times
Disturbed self-organization and dissociation; schema of self as damaged or unworthy
Interpersonal problems ranging from dependence on others to hyper-independence, lack of trust in others to total unfounded trust even in strangers
Dissociative fragmentation from body and/or the present state
Associated symptoms that are not always present or required for diagnosis include health problems: seizures, migraines, gastrointestinal issues, autoimmune disorders, fibromyalgia, chronic fatigue, and somatic symptoms without explanation.
There are many hidden sources of trauma that go beneath our conscious awareness but are still held by the body. These can include preverbal trauma, perinatal trauma, epigenetic factors, transgenerational trauma, poor modeling of health-promoting behaviors, learning disability, sociocultural factors, and a lack of resilience factors. These often show up as signs of threat in your body. You can also discover the presence of hidden trauma by looking for psychological defendedness and tracing them back to an initial point where the defenses were adaptive. On the flip side, we can demonstrate a lack of hidden trauma by looking for signs of regulation and social engagement.
Modified EMDR for C-PTSD
The greatest predictor of meaningful change in therapy is the quality of the relationship between therapist and client. All therapy requires personalization and modification to fit the modality to the unique history, goals, and needs of each individual client.
Traumatic memories are like isolated islands, not properly encoded or integrated into your neural networks of memory. These trauma memories have a limited ability to accommodate new information, positive affect, or resourcing sensations that may otherwise be helpful. This encapsulated self state impairs your emotional flexibility and your ability to construct new cognitions. Fortunately, neuroplastic change continues through life, so the work of therapy is to build bridges to reconnect these isolated memories to the fullness of your resources and conscious understanding.
The primary function of memory is to help us predict or anticipate new experiences based on prior knowledge. Cognitive dissonance between the expected outcome and actual outcome activates our neuroplasticity so we are able to learn. Memory is malleable and constructive, influenced by both internal and external factors.
The AIP model of EMDR holds that people have an inherent capacity to heal given sufficient support. The process of EMDR includes purposeful reflective remembering and cognitive reappraisal of trauma memories. Sessions target negative thoughts and attachment representations while promoting emotion regulation. The bilateral stimulation promotes dual attention linking your current safety in the present moment with your emotions, memories, or sensations associated with the trauma.
With C-PTSD, EMDR should be modified to make it more accessible and easier to tolerate. Instead of going into memories based on what happened first chronologically or which were the worst incidents, sessions can focus on current symptoms or distress. This allows for a more gentle initiation into reprocessing while maintaining the window of tolerance between hyper- and hypo-arousal. We can also allow for any positive shift to be meaningful rather than an insistence on SUD 0 and VOC 7. Finally, we need to stay attuned to somatic cues of flooding. We may use more interweaves, bring in other interventions, or use modified protocols.
The modified protocol for neglect shifts the focus from reprocessing and desensitizing an active experience. Instead, we will repair your missing experiences and process that loss of positive experience. For dissociation, we can take a progressive approach that focuses strongly on interweaves. With people who have a strong defense of intellectualization and with people who had preverbal traumas, we use a sensation-based focus and a bottom-up approach to work with somatic trauma rather than explicit memory. Any form of C-PTSD can benefit from pendulation work to help you feel more in control of your experience.
The key with this work is making sure you have choice and containment. When we have no choices, the feeling of being trapped leads to a sense of threat. It’s important that therapy creates a sense of safety through giving you choice. You choose when and how to access your trauma memory and somatic feelings. We create containment by setting limits on what and how much we access traumatic memories. As a client, you always have unconditional permission to distance yourself from your distress.